Provider Demographics
NPI:1336480854
Name:OLSON, PAUL THEODORE (LMSW)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:THEODORE
Last Name:OLSON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 CLEVELAND AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:ISHPEMING
Mailing Address - State:MI
Mailing Address - Zip Code:49849-1842
Mailing Address - Country:US
Mailing Address - Phone:906-290-7492
Mailing Address - Fax:
Practice Address - Street 1:308 CLEVELAND AVE STE 302
Practice Address - Street 2:
Practice Address - City:ISHPEMING
Practice Address - State:MI
Practice Address - Zip Code:49849-1842
Practice Address - Country:US
Practice Address - Phone:906-290-7492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-07
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010902281041C0700X
MIL2003492101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI12511462OtherCAQH ID