Provider Demographics
NPI:1790059475
Name:OLSON, LETITIA
Entity Type:Individual
Prefix:
First Name:LETITIA
Middle Name:
Last Name:OLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7345 HIGHWAY 62 W
Mailing Address - Street 2:
Mailing Address - City:GASSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72635-8636
Mailing Address - Country:US
Mailing Address - Phone:870-435-5511
Mailing Address - Fax:870-435-5513
Practice Address - Street 1:7345 HIGHWAY 62 W
Practice Address - Street 2:
Practice Address - City:GASSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72635-8636
Practice Address - Country:US
Practice Address - Phone:870-435-5511
Practice Address - Fax:870-435-5513
Is Sole Proprietor?:No
Enumeration Date:2012-02-28
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR07-03E103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist