Provider Demographics
NPI:1790804409
Name:OLSON, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
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 1:1201 25TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2311
Mailing Address - Country:US
Mailing Address - Phone:701-451-4900
Mailing Address - Fax:651-925-0057
Practice Address - Street 1:1201 25TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2311
Practice Address - Country:US
Practice Address - Phone:701-451-4900
Practice Address - Fax:651-925-0057
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1074106H00000X
ND2009-023106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP51290OtherHEALTH PARTNERS
MN245K1OLOtherBCBS MN
MN3100200502OtherPRIMEWEST HEALTH
MN56560-B005OtherTRIWEST
MN727623100Medicaid
MN9398252OtherPHCS
MN2352433OtherAMERICA'S PPO