Provider Demographics
NPI:1932872934
Name:OLESON, STEPHANIE (PHD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:OLESON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 PEERLESS PL APT 301
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-2870
Mailing Address - Country:US
Mailing Address - Phone:858-344-6622
Mailing Address - Fax:
Practice Address - Street 1:1420 PEERLESS PL APT 301
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-2870
Practice Address - Country:US
Practice Address - Phone:858-344-6222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY32717103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist