Provider Demographics
NPI:1629549217
Name:OLSON BEELEK, KRISTINE GAIL
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:GAIL
Last Name:OLSON BEELEK
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 1:1381 E LANTERN LN
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-5643
Mailing Address - Country:US
Mailing Address - Phone:801-712-6768
Mailing Address - Fax:
Practice Address - Street 1:4505 S WASATCH BLVD STE 290
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-4204
Practice Address - Country:US
Practice Address - Phone:385-695-5949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-08
Last Update Date:2018-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT329189-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist