Provider Demographics
NPI:1699223370
Name:OLSEN, TIMOTHY
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:OLSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5905 W EASTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-3104
Mailing Address - Country:US
Mailing Address - Phone:312-545-5247
Mailing Address - Fax:
Practice Address - Street 1:5905 W EASTWOOD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-3104
Practice Address - Country:US
Practice Address - Phone:312-545-5247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-12
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health