Provider Demographics
NPI:1407572118
Name:OLSON, SPENCER WENDELL
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:WENDELL
Last Name:OLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-1441
Mailing Address - Country:US
Mailing Address - Phone:208-360-4294
Mailing Address - Fax:
Practice Address - Street 1:205 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274-1441
Practice Address - Country:US
Practice Address - Phone:208-360-4294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child