1144239047 NPI number — SUSAN M OLSON LCPC

Table of content: SUSAN M OLSON LCPC (NPI 1144239047)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144239047 NPI number — SUSAN M OLSON LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLSON
Provider First Name:
SUSAN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STRUM
Provider Other First Name:
SUSAN
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS LCPC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1144239047
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1509
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELGIN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60121-1509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
224-238-4160
Provider Business Mailing Address Fax Number:
847-783-0599

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1121 E MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
ST CHARLES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60174-2205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-513-5576
Provider Business Practice Location Address Fax Number:
630-513-5657
Provider Enumeration Date:
08/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  180001663 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 04532734 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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