Healthcare Provider Details

I. General information

NPI: 1063092716
Provider Name (Legal Business Name): OLIVE TREE COUNSELING LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2021
Last Update Date: 04/08/2021
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N. STATELINE AVENUE
TEXARKANA AR
71854
US

IV. Provider business mailing address

3930 GALLERIA OAKS
TEXARKANA TX
75503
US

V. Phone/Fax

Practice location:
  • Phone: 903-336-3484
  • Fax: 903-336-3484
Mailing address:
  • Phone: 903-336-3484
  • Fax: 903-336-3484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: RANDY ERVIN THOMASON JR.
Title or Position: CO-OWNER
Credential: LPC
Phone: 903-336-3484