Provider Demographics
NPI:1134780042
Name:OLSEN, MICHAEL JAMES (PEER SUPPORT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:OLSEN
Suffix:
Gender:M
Credentials:PEER SUPPORT
Other - Prefix:
Other - First Name:TISHA
Other - Middle Name:MARIE
Other - Last Name:OLSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:344 E 100 S STE 301300
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-1700
Mailing Address - Country:US
Mailing Address - Phone:801-428-3475
Mailing Address - Fax:
Practice Address - Street 1:344 E 100 S STE 301300
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1700
Practice Address - Country:US
Practice Address - Phone:801-428-3475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-23
Last Update Date:2019-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist