Basic Information
| Provider Information | |||||||||
| NPI: | 1538204706 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLSON | ||||||||
| FirstName: | PATRICIA | ||||||||
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| Credential: | MED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 813 12TH AVE N | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581022625 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1201 25TH ST S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581032311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014514900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 01/11/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 00154 | MN | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 327-8-1-95-93 | ND | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 58103-003A | 01 | ND | 9400692 | OTHER | 9400692 | 01 | ND | PHCS | OTHER | 6575850 | 05 | SD | MEDICAID | 137157 | 01 | NC | TRIWEST | OTHER | 62-67338 | 01 | ND | MEDICA UBH | OTHER | 2327563 | 01 | ND | AMERICA'S PPO | OTHER | 990991045437 | 01 | ND | BHP PREFERRED 1 | OTHER | 18051 | 01 | ND | BCBSND | OTHER | HP52676 | 01 | ND | HEALTH PARTNERS | OTHER | 309S90L | 01 | MN | BCBSMN | OTHER |