Provider Demographics
NPI:1275887275
Name:OLSEN, LINDSEY
Entity Type:Individual
Prefix:
First Name:LINDSEY
Middle Name:
Last Name:OLSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 DOUGLAS AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-5365
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3125 DOUGLAS AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-5365
Practice Address - Country:US
Practice Address - Phone:515-523-1150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-30
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000371251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1073664694Medicaid