Provider Demographics
NPI:1588722524
Name:OLSON, SPENCER (LP)
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:
Last Name:OLSON
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6120 EARLE BROWN DR
Mailing Address - Street 2:SUITE 520
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-2123
Mailing Address - Country:US
Mailing Address - Phone:763-531-0566
Mailing Address - Fax:763-531-0602
Practice Address - Street 1:6120 EARLE BROWN DR
Practice Address - Street 2:SUITE 520
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2123
Practice Address - Country:US
Practice Address - Phone:763-531-0566
Practice Address - Fax:763-531-0602
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0838103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN94388OtherOPTUM
MN75232OtherCIGNA EAP
MN364748000Medicaid
MN45Q72OLOtherBCBS
MN6164000OtherMEDICA CHOICE
MN101832C154OtherUCARE
MNHP19966OtherHEALTHPARTNERS
MN411425197OtherCIGNA BEHAVIORAL HEALTH
MN680009018OtherRR MEDICARE
MN364748000Medicaid