MEDICARE: OLIVIA THERESA TISE MSW, LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	24523	MN
2	1041C0700X	Clinical Social Worker	67106	TX

General Provider Information

NPI Number	:	1538654926
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVIA THERESA TISE MSW, LCSW

Provider Business Mailing Address
First Line	:	13400 BRIARWICK DR UNIT 304
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78729-1769
Country	:	US
Telephone Number	:	952-451-8576
Fax Number	:

Provider Business Practice Location Address
First Line	:	13400 BRIARWICK DR UNIT 304
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78729-1769
Country	:	US
Telephone Number	:	952-451-8576
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2018
Last Update Date	:	03/01/2021

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