Provider Demographics
NPI:1285004143
Name:OLSON, AMY L (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:OLSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:L
Other - Last Name:DICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:11956 W FAIRVIEW AVE APT J115
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-8089
Mailing Address - Country:US
Mailing Address - Phone:208-252-0847
Mailing Address - Fax:
Practice Address - Street 1:1835 WILDWOOD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-5146
Practice Address - Country:US
Practice Address - Phone:208-252-0847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-03
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO67620353Medicaid