Provider Demographics
NPI:1508510678
Name:OLSON, AUTUMN
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:OLSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6366 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-4920
Mailing Address - Country:US
Mailing Address - Phone:920-857-9041
Mailing Address - Fax:920-857-3366
Practice Address - Street 1:6366 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-4920
Practice Address - Country:US
Practice Address - Phone:920-857-9041
Practice Address - Fax:920-857-3366
Is Sole Proprietor?:No
Enumeration Date:2022-02-08
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MO1-25-79662103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician