Provider Demographics
NPI:1760842140
Name:OLSON, STEPHANIE (BA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:OLSON
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2785 EAGLE DR
Mailing Address - Street 2:B-105
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-5711
Mailing Address - Country:US
Mailing Address - Phone:208-528-4065
Mailing Address - Fax:
Practice Address - Street 1:150 SHOUP AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3657
Practice Address - Country:US
Practice Address - Phone:208-528-4065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist