Basic Information
| Provider Information | |||||||||
| NPI: | 1619256088 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLSON | ||||||||
| FirstName: | GWEN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCHRAMER | ||||||||
| OtherFirstName: | GWEN | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1401 EAST FIRST STREET | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187284404 | ||||||||
| FaxNumber: | 2187284404 | ||||||||
| Practice Location | |||||||||
| Address1: | 4000 W 9TH ST | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558071563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186252685 | ||||||||
| FaxNumber: | 2186252697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2011 | ||||||||
| LastUpdateDate: | 06/06/2012 | ||||||||
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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 | 106H00000X | 2148 | MN | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.