Provider Demographics
NPI:1700971850
Name:OLSEN, BROOKE RIGNEY (PHD, HSPP)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:RIGNEY
Last Name:OLSEN
Suffix:
Gender:F
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8290 W 350 N
Mailing Address - Street 2:
Mailing Address - City:THORNTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46071-9324
Mailing Address - Country:US
Mailing Address - Phone:765-446-9394
Mailing Address - Fax:
Practice Address - Street 1:3660 ROME DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4488
Practice Address - Country:US
Practice Address - Phone:765-446-9394
Practice Address - Fax:765-447-8875
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040667A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN070930BMedicare ID - Type Unspecified