Provider Demographics
NPI:1215907886
Name:OLSEN, MICHAEL STEWART (LCSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STEWART
Last Name:OLSEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 3 BOX A2
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-8901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:361 E 1200 S
Practice Address - Street 2:SUITE 201
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-6904
Practice Address - Country:US
Practice Address - Phone:801-556-8368
Practice Address - Fax:801-224-4914
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT136916-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT13691635000001OtherBLUE CROSS
UT942938348113OtherUNKNOWN COMPANY
UT261923OtherDESERT MUTUAL
UT107001387101OtherINTRMTN. HEATH CARE
UT9429383483480L1OtherEDUCATORS MUTUAL
UT13691635000001OtherBLUE CROSS
UT107001387101OtherINTRMTN. HEATH CARE
UT260002932Medicare ID - Type Unspecified