Provider Demographics
NPI:1942237672
Name:OLESNAVAGE, JOHN JOSEPH (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JOSEPH
Last Name:OLESNAVAGE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3926 SQUAW BEACH ROAD
Mailing Address - Street 2:P O BOX 254
Mailing Address - City:BIG BAY
Mailing Address - State:MI
Mailing Address - Zip Code:49808-0254
Mailing Address - Country:US
Mailing Address - Phone:906-250-4799
Mailing Address - Fax:
Practice Address - Street 1:3926 SQUAW BEACH ROAD
Practice Address - Street 2:
Practice Address - City:BIG BAY
Practice Address - State:MI
Practice Address - Zip Code:49808-0254
Practice Address - Country:US
Practice Address - Phone:906-250-4799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010173103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI237649000OtherMAGELLAN HEALTH
MI680E210290OtherBCBSM PIN NUMBER
MIG96288057Medicare PIN
MI680E210290OtherBCBSM PIN NUMBER