Provider Demographics
NPI:1881903417
Name:OLSON, KENNETH (LCPC)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:OLSON
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 GANNETT DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3269
Mailing Address - Country:US
Mailing Address - Phone:207-771-5712
Mailing Address - Fax:207-771-5750
Practice Address - Street 1:324 GANNETT DR STE 300
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-3269
Practice Address - Country:US
Practice Address - Phone:207-771-5712
Practice Address - Fax:207-771-5750
Is Sole Proprietor?:No
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC808101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional