Provider Demographics
NPI:1720559347
Name:OLSEN, MIRANDA MAY (BCBA)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:MAY
Last Name:OLSEN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-4649
Mailing Address - Country:US
Mailing Address - Phone:860-221-4717
Mailing Address - Fax:
Practice Address - Street 1:1501 DOGWOOD DR
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-4649
Practice Address - Country:US
Practice Address - Phone:860-221-4717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-07
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI251-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst