Healthcare Provider Details

I. General information

NPI: 1245369842
Provider Name (Legal Business Name): OLGA A EBALAROSA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 04/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 LOUISIANA BLVD NE STE C
ALBUQUERQUE NM
87110-1448
US

IV. Provider business mailing address

5801 LOWELL ST NE APT 11B
ALBUQUERQUE NM
87111-5900
US

V. Phone/Fax

Practice location:
  • Phone: 505-888-1686
  • Fax: 505-888-1683
Mailing address:
  • Phone: 505-888-1686
  • Fax: 505-888-1683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-08728
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: