Provider Demographics
NPI:1851459614
Name:OLSON, KENNETH A (MA, MFT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:OLSON
Suffix:
Gender:M
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9033 BASELINE RD
Mailing Address - Street 2:H
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-1255
Mailing Address - Country:US
Mailing Address - Phone:909-989-9030
Mailing Address - Fax:909-466-4594
Practice Address - Street 1:9033 BASELINE RD, SUITE H
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730
Practice Address - Country:US
Practice Address - Phone:909-989-9030
Practice Address - Fax:909-466-4594
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC27997106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist