Provider Demographics
NPI:1629676424
Name:OLSON, ARCHY
Entity Type:Individual
Prefix:
First Name:ARCHY
Middle Name:
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 1:434 HAYWARD AVE N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5379
Mailing Address - Country:US
Mailing Address - Phone:651-739-2300
Mailing Address - Fax:
Practice Address - Street 1:2 SHORELINE PL
Practice Address - Street 2:
Practice Address - City:SPRING PARK
Practice Address - State:MN
Practice Address - Zip Code:55384-9644
Practice Address - Country:US
Practice Address - Phone:952-297-7720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician