Provider Demographics
NPI:1790942704
Name:OLSON, GARY THOMAS (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:THOMAS
Last Name:OLSON
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7625 METRO BLVD
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55439-3053
Mailing Address - Country:US
Mailing Address - Phone:952-945-4070
Mailing Address - Fax:
Practice Address - Street 1:7625 METRO BLVD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55439-3053
Practice Address - Country:US
Practice Address - Phone:952-945-4070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN175661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical