Provider Demographics
NPI:1427263912
Name:OLESON, TERRENCE DALE (PHD)
Entity type:Individual
Prefix:
First Name:TERRENCE
Middle Name:DALE
Last Name:OLESON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:TERRY
Other - Middle Name:
Other - Last Name:OLESON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:8170 BEVERLY BLVD
Mailing Address - Street 2:#108
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-4524
Mailing Address - Country:US
Mailing Address - Phone:323-653-5781
Mailing Address - Fax:323-656-2085
Practice Address - Street 1:8170 BEVERLY BLVD
Practice Address - Street 2:#108
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4524
Practice Address - Country:US
Practice Address - Phone:323-653-5781
Practice Address - Fax:323-656-2085
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 5127103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical