Provider Demographics
NPI:1811555634
Name:OLSEN, GASTON ROBERT (LAC, LMT)
Entity Type:Individual
Prefix:
First Name:GASTON
Middle Name:ROBERT
Last Name:OLSEN
Suffix:
Gender:M
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 UNION SQ E STE 612N
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-3243
Mailing Address - Country:US
Mailing Address - Phone:917-658-9097
Mailing Address - Fax:
Practice Address - Street 1:32 UNION SQ E STE 612N
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3243
Practice Address - Country:US
Practice Address - Phone:917-658-9097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018439225700000X
NY018439-01225700000X
NY006770-01171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist