Provider Demographics
NPI:1790878957
Name:OLAUGHLIN, MICHAEL SHAWN (PHD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:SHAWN
Last Name:OLAUGHLIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 12TH ST NORTH
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:56520
Mailing Address - Country:US
Mailing Address - Phone:218-643-8714
Mailing Address - Fax:
Practice Address - Street 1:510 4TH ST SOUTH
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103
Practice Address - Country:US
Practice Address - Phone:701-476-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND350103T00000X
MN3493103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND11928Medicaid
ND21840Medicare ID - Type Unspecified