Healthcare Provider Details

I. General information

NPI: 1255435608
Provider Name (Legal Business Name): JANET S OLIVER LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

09 LLANO VISTA RD BLACK LAKE DIVISION
ANGEL FIRE NM
87710
US

IV. Provider business mailing address

P.O. BOX 1319
ANGEL FIRE NM
87710
US

V. Phone/Fax

Practice location:
  • Phone: 505-377-3193
  • Fax:
Mailing address:
  • Phone: 505-377-3193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number91521
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: