Provider Demographics
NPI:1881658540
Name:OLSON, THEODORE EVOR (MDIV, MS)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:EVOR
Last Name:OLSON
Suffix:
Gender:M
Credentials:MDIV, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 CATHEDRAL DR
Mailing Address - Street 2:
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-1066
Mailing Address - Country:US
Mailing Address - Phone:215-412-7863
Mailing Address - Fax:
Practice Address - Street 1:1107 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-3143
Practice Address - Country:US
Practice Address - Phone:610-644-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC003466101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health