Basic Information
| Provider Information | |||||||||
| NPI: | 1710635438 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLSEN | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | RAYMOND | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | SUDP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981225307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257579081 | ||||||||
| FaxNumber: | 5093254580 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981225307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257579081 | ||||||||
| FaxNumber: | 5093254580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2022 | ||||||||
| LastUpdateDate: | 08/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CP61200273 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | CP61200273 | 01 | WA | WASHINGTON DEPARTMENT OF HEALTH | OTHER |