Basic Information
Provider Information
NPI: 1003008202
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: OLIVER
FirstName: ANGELA
MiddleName: D.
NamePrefix:  
NameSuffix:  
Credential: LCSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 278
Address2:  
City: EL PRADO
State: NM
PostalCode: 875290278
CountryCode: US
TelephoneNumber: (575) 751-9858
FaxNumber: 5756131506
Practice Location
Address1: 244 TUNE DRIVE
Address2:  
City: EL PRADO
State: NM
PostalCode: 87529
CountryCode: US
TelephoneNumber: 5757519858
FaxNumber: 5757519858
Other Information
ProviderEnumerationDate: 08/13/2007
LastUpdateDate: 03/17/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YM0800XI-06235NMN Behavioral Health & Social Service ProvidersCounselorMental Health
1041C0700XC-06235NMY Behavioral Health & Social Service ProvidersSocial WorkerClinical

ID Information
IDTypeStateIssuerDescription
9988136505NM MEDICAID


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