Provider Demographics
NPI:1285892414
Name:OLSON, PAMELA MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:MARIE
Last Name:OLSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:548 N LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILLIPS
Mailing Address - State:WI
Mailing Address - Zip Code:54555-1028
Mailing Address - Country:US
Mailing Address - Phone:715-339-6453
Mailing Address - Fax:715-339-6450
Practice Address - Street 1:548 N LAKE AVE
Practice Address - Street 2:
Practice Address - City:PHILLIPS
Practice Address - State:WI
Practice Address - Zip Code:54555-1028
Practice Address - Country:US
Practice Address - Phone:715-339-6453
Practice Address - Fax:715-339-6450
Is Sole Proprietor?:No
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1865-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39762300Medicaid