Provider Demographics
NPI:1700139920
Name:OLSON, LESLIE RENAE (BA, CADC)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:RENAE
Last Name:OLSON
Suffix:
Gender:F
Credentials:BA, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 KELLOGG AVE
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-6234
Mailing Address - Country:US
Mailing Address - Phone:515-233-4930
Mailing Address - Fax:
Practice Address - Street 1:804 KELLOGG AVE
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-6234
Practice Address - Country:US
Practice Address - Phone:515-233-4930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA12021101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)