Provider Demographics
NPI:1124047865
Name:OLSON, GLADYS A (LICSW)
Entity type:Individual
Prefix:
First Name:GLADYS
Middle Name:A
Last Name:OLSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:GLADYS
Other - Middle Name:
Other - Last Name:ABRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:109 SALEM ST
Mailing Address - Street 2:#301
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-1100
Mailing Address - Country:US
Mailing Address - Phone:781-388-9871
Mailing Address - Fax:
Practice Address - Street 1:1132 WESTFIELD ST
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-3878
Practice Address - Country:US
Practice Address - Phone:413-592-1980
Practice Address - Fax:413-439-0096
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10194681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA62-00464OtherEVERCARE
MA62-00464OtherEVERCARE
MAP22926Medicare ID - Type Unspecified