Provider Demographics
NPI:1386730141
Name:OLSON, G. KEITH (PHD)
Entity type:Individual
Prefix:
First Name:G.
Middle Name:KEITH
Last Name:OLSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 CAMINO DEL RIO S
Mailing Address - Street 2:SUITE 315
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3717
Mailing Address - Country:US
Mailing Address - Phone:619-280-3430
Mailing Address - Fax:
Practice Address - Street 1:2525 CAMINO DEL RIO S
Practice Address - Street 2:SUITE 315
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3717
Practice Address - Country:US
Practice Address - Phone:619-280-3430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 6022106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist