Basic Information
| Provider Information | |||||||||
| NPI: | 1306906755 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLSON | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OLSON | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMFT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1841 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BARSTOW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923113234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602555700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1841 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BARSTOW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923113234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602555700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 11/09/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC41200 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 103TC0700X | PSY33664 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.