Provider Demographics
NPI:1285748764
Name:OLSON, LARRY JAMES (MA,CCC-A)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:JAMES
Last Name:OLSON
Suffix:
Gender:M
Credentials:MA,CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13762 EMBER RD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-7332
Mailing Address - Country:US
Mailing Address - Phone:605-342-3207
Mailing Address - Fax:
Practice Address - Street 1:13762 EMBER RD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-7332
Practice Address - Country:US
Practice Address - Phone:605-342-3207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD018A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5830480Medicaid