Provider Demographics
NPI:1942590765
Name:OLSEN, GARY LLOYD (LCSW)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LLOYD
Last Name:OLSEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 PEARL CIR
Mailing Address - Street 2:
Mailing Address - City:SUSANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96130-5110
Mailing Address - Country:US
Mailing Address - Phone:530-252-6595
Mailing Address - Fax:530-252-6595
Practice Address - Street 1:1816 FIRST STREET
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130-5110
Practice Address - Country:US
Practice Address - Phone:530-252-6595
Practice Address - Fax:530-252-6595
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-13
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1942590765Medicare PIN