Provider Demographics
NPI:1659565026
Name:PHYLLIS M OLSON PSYD HSPP LLC
Entity Type:Organization
Organization Name:PHYLLIS M OLSON PSYD HSPP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, HSPP
Authorized Official - Phone:765-622-7622
Mailing Address - Street 1:3310 S MAIN ST
Mailing Address - Street 2:SUITE D1
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46013-4234
Mailing Address - Country:US
Mailing Address - Phone:765-622-7622
Mailing Address - Fax:
Practice Address - Street 1:3310 S MAIN ST
Practice Address - Street 2:SUITE D1
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46013-4234
Practice Address - Country:US
Practice Address - Phone:765-622-7622
Practice Address - Fax:765-622-9032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041304A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty