1316116254 NPI number — GENELLE D. OLSON LSW

Table of content: GENELLE D. OLSON LSW (NPI 1316116254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316116254 NPI number — GENELLE D. OLSON LSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLSON
Provider First Name:
GENELLE
Provider Middle Name:
D.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316116254
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3850 247TH AVE SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAX
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58759-9527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-739-4528
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 4TH AVE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEVILS LAKE
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58301-2418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-662-4913
Provider Business Practice Location Address Fax Number:
701-662-4963
Provider Enumeration Date:
02/25/2008

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: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171M00000X , with the licence number: 2726 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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