Provider Demographics
NPI:1942014345
Name:OLSEN, MAX RYAN (BA)
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:RYAN
Last Name:OLSEN
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3807 WHITE RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95252-9584
Mailing Address - Country:US
Mailing Address - Phone:925-813-8798
Mailing Address - Fax:
Practice Address - Street 1:2291 W MARCH LN STE C101
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6669
Practice Address - Country:US
Practice Address - Phone:888-512-2695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician