Provider Demographics
NPI:1699222083
Name:OLSON, LACY ASHTON (PHD)
Entity Type:Individual
Prefix:DR
First Name:LACY
Middle Name:ASHTON
Last Name:OLSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6404 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 870
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5501
Mailing Address - Country:US
Mailing Address - Phone:800-624-1475
Mailing Address - Fax:
Practice Address - Street 1:6404 WILSHIRE BLVD
Practice Address - Street 2:SUITE 870
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5501
Practice Address - Country:US
Practice Address - Phone:800-624-1475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-02
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28437103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical