Provider Demographics
NPI:1740331586
Name:OLSON, ROGER (PSYD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:
Last Name:OLSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 140037
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-0037
Mailing Address - Country:US
Mailing Address - Phone:208-938-1236
Mailing Address - Fax:
Practice Address - Street 1:13177 W PERSIMMON LN STE 102
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1986
Practice Address - Country:US
Practice Address - Phone:208-938-1236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-385103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical