Provider Demographics
NPI:1760671671
Name:OLESNAVAGE PSYCHOLOGICAL SERVICES PC
Entity Type:Organization
Organization Name:OLESNAVAGE PSYCHOLOGICAL SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:OLESNAVAGE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:906-225-1071
Mailing Address - Street 1:106 COLES DR
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4010
Mailing Address - Country:US
Mailing Address - Phone:906-225-1071
Mailing Address - Fax:906-225-1074
Practice Address - Street 1:106 COLES DR
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4010
Practice Address - Country:US
Practice Address - Phone:906-225-1071
Practice Address - Fax:906-225-1074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010173103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N96270Medicare PIN