Provider Demographics
NPI:1912141607
Name:OLSON, JOHN
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:OLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19003 MUIRLAND ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-2289
Mailing Address - Country:US
Mailing Address - Phone:248-752-7950
Mailing Address - Fax:586-416-6152
Practice Address - Street 1:1270 DORIS RD
Practice Address - Street 2:
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-2617
Practice Address - Country:US
Practice Address - Phone:248-752-7950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-24
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802069440104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker