Provider Demographics
NPI:1659050516
Name:OLSON, MALLORY (BS)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:OLSON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:DANIELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2620 STEIN BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-2674
Mailing Address - Country:US
Mailing Address - Phone:715-836-0064
Mailing Address - Fax:
Practice Address - Street 1:312 W KNAPP ST STE B
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-1631
Practice Address - Country:US
Practice Address - Phone:715-836-0064
Practice Address - Fax:715-836-0065
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
WI8006-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst