Provider Demographics
NPI:1639710593
Name:OLSON, ALICIA MARIE
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:MARIE
Last Name:OLSON
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 1:25844 10TH ST W
Mailing Address - Street 2:
Mailing Address - City:ZIMMERMAN
Mailing Address - State:MN
Mailing Address - Zip Code:55398-8796
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25844 10TH ST W
Practice Address - Street 2:
Practice Address - City:ZIMMERMAN
Practice Address - State:MN
Practice Address - Zip Code:55398-8796
Practice Address - Country:US
Practice Address - Phone:763-202-9054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1101018320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities