Provider Demographics
NPI:1154105500
Name:OLSTAD, JOHN THOMAS (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:THOMAS
Last Name:OLSTAD
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 E MEINECKE AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-3433
Mailing Address - Country:US
Mailing Address - Phone:414-241-1152
Mailing Address - Fax:
Practice Address - Street 1:1706 S 68TH ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-4949
Practice Address - Country:US
Practice Address - Phone:414-667-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14294-33363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health