Provider Demographics
NPI:1649519992
Name:OLSON, TINA L (LADC)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:L
Last Name:OLSON
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24641 FONDANT AVE
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-8797
Mailing Address - Country:US
Mailing Address - Phone:651-249-5171
Mailing Address - Fax:
Practice Address - Street 1:1885 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 246
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3489
Practice Address - Country:US
Practice Address - Phone:612-326-7565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-06
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303001101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)