Provider Demographics
NPI:1295923795
Name:CRAIG D. OLSON, PSY.D.
Entity type:Organization
Organization Name:CRAIG D. OLSON, PSY.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-609-7830
Mailing Address - Street 1:300 PATTERSON RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45419-3933
Mailing Address - Country:US
Mailing Address - Phone:937-890-9804
Mailing Address - Fax:937-293-3884
Practice Address - Street 1:7071 CORPORATE WAY
Practice Address - Street 2:SUITE 106
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-8911
Practice Address - Country:US
Practice Address - Phone:937-890-9804
Practice Address - Fax:937-293-3884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4487103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCP14401Medicare PIN