Provider Demographics
NPI:1962427187
Name:OLSON, PHYLLIS M
Entity type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:M
Last Name:OLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 605
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:IN
Mailing Address - Zip Code:46001-0605
Mailing Address - Country:US
Mailing Address - Phone:765-233-1102
Mailing Address - Fax:765-233-1103
Practice Address - Street 1:3310 S MAIN STREET
Practice Address - Street 2:SUITE D1
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46013-4234
Practice Address - Country:US
Practice Address - Phone:765-622-7622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041304A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200203950Medicaid