Provider Demographics
NPI:1750108478
Name:OLSEN, DIANE (PCLC)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:OLSEN
Suffix:
Gender:F
Credentials:PCLC
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 1904
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-1904
Mailing Address - Country:US
Mailing Address - Phone:406-298-5161
Mailing Address - Fax:
Practice Address - Street 1:504 FORD ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-4245
Practice Address - Country:US
Practice Address - Phone:406-298-5161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-PCLC-LIC-64864101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health