Provider Demographics
NPI:1730286121
Name:HENDERSON-OLSON, DELORES (BS)
Entity Type:Individual
Prefix:
First Name:DELORES
Middle Name:
Last Name:HENDERSON-OLSON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CADCIII
Mailing Address - Street 1:11 FIFTH AVE
Mailing Address - Street 2:PO BOX 265
Mailing Address - City:SHELL LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54871-0265
Mailing Address - Country:US
Mailing Address - Phone:715-468-2841
Mailing Address - Fax:715-468-2374
Practice Address - Street 1:11 FIFTH AVE
Practice Address - Street 2:
Practice Address - City:SHELL LAKE
Practice Address - State:WI
Practice Address - Zip Code:54871-0265
Practice Address - Country:US
Practice Address - Phone:715-468-2841
Practice Address - Fax:715-468-2374
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3937990Medicaid