Provider Demographics
NPI:1669555363
Name:OLSEN, MARY G (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:G
Last Name:OLSEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6940 SW BAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-2518
Mailing Address - Country:US
Mailing Address - Phone:503-684-6345
Mailing Address - Fax:503-968-9522
Practice Address - Street 1:6940 SW BAYLOR ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-2518
Practice Address - Country:US
Practice Address - Phone:503-684-6345
Practice Address - Fax:503-968-9522
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0880103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000TCPHFSPECD8Medicare ID - Type Unspecified