Provider Demographics
NPI:1972524650
Name:PHILLIPS OLSON, PAMELA (LCSW)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:PHILLIPS OLSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18549 COUNTY HWY A
Mailing Address - Street 2:
Mailing Address - City:RICHLAND CENTER
Mailing Address - State:WI
Mailing Address - Zip Code:53581-8662
Mailing Address - Country:US
Mailing Address - Phone:608-647-8220
Mailing Address - Fax:608-647-8162
Practice Address - Street 1:715 HILL ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-3576
Practice Address - Country:US
Practice Address - Phone:608-233-7431
Practice Address - Fax:608-647-8162
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2122-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39255500Medicaid
WIWI1988001Medicare PIN