Provider Demographics
NPI:1467755959
Name:OLSON, CHRISTIAN WILLIAM
Entity Type:Individual
Prefix:MR
First Name:CHRISTIAN
Middle Name:WILLIAM
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 1:1250 PALM ST
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33755-1129
Mailing Address - Country:US
Mailing Address - Phone:727-510-4584
Mailing Address - Fax:727-442-2211
Practice Address - Street 1:1250 PALM ST
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33755-1129
Practice Address - Country:US
Practice Address - Phone:727-510-4584
Practice Address - Fax:727-442-2211
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002247100Medicaid