Provider Demographics
NPI:1669701827
Name:SUSAN J OLSON MD - PSYCHIATRIC SERVICES LLC
Entity type:Organization
Organization Name:SUSAN J OLSON MD - PSYCHIATRIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENT FOR CORPORATION
Authorized Official - Prefix:MR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:LICARY
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:843-712-1854
Mailing Address - Street 1:333 WELCOME DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-5374
Mailing Address - Country:US
Mailing Address - Phone:843-712-1854
Mailing Address - Fax:
Practice Address - Street 1:333 WELCOME DR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-5374
Practice Address - Country:US
Practice Address - Phone:843-712-1854
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-17
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E97214Medicare UPIN