Provider Demographics
NPI:1396097911
Name:OLSEN, KENNETH BRENT (PSYD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:BRENT
Last Name:OLSEN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 E CAMERON ST
Mailing Address - Street 2:
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-3121
Mailing Address - Country:US
Mailing Address - Phone:559-772-8427
Mailing Address - Fax:
Practice Address - Street 1:1 KINGS WAY
Practice Address - Street 2:
Practice Address - City:AVENAL
Practice Address - State:CA
Practice Address - Zip Code:93204-9708
Practice Address - Country:US
Practice Address - Phone:559-386-0587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-05
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 22757103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical