Provider Demographics
NPI:1245097856
Name:OLSON, MADELEINE MCKENZIE
Entity type:Individual
Prefix:
First Name:MADELEINE
Middle Name:MCKENZIE
Last Name:OLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12424 WILSHIRE BLVD STE 650
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1081
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12424 WILSHIRE BLVD STE 650
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1081
Practice Address - Country:US
Practice Address - Phone:310-571-8760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA142979106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist