Provider Demographics
NPI:1922512334
Name:OLSEN, MELISSA (MFT-IT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:OLSEN
Suffix:
Gender:F
Credentials:MFT-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 W NETHERWOOD ST STE A
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:WI
Mailing Address - Zip Code:53575-1107
Mailing Address - Country:US
Mailing Address - Phone:608-835-5050
Mailing Address - Fax:608-835-5010
Practice Address - Street 1:165 W NETHERWOOD ST STE A
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:WI
Practice Address - Zip Code:53575-1107
Practice Address - Country:US
Practice Address - Phone:608-835-5050
Practice Address - Fax:608-835-5050
Is Sole Proprietor?:No
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI582-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI582-228OtherSTATE LICENSE