Basic Information
| Provider Information | |||||||||
| NPI: | 1336320951 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLESON | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286382328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8287268265 | ||||||||
| FaxNumber: | 8283278796 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286382328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8287268265 | ||||||||
| FaxNumber: | 8283278796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2007 | ||||||||
| LastUpdateDate: | 08/25/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C000459 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6106807 | 05 | NC | MEDICAID |