Healthcare Provider Details

I. General information

NPI: 1003008202
Provider Name (Legal Business Name): ANGELA D. OLIVER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 TUNE DRIVE
EL PRADO NM
87529
US

IV. Provider business mailing address

PO BOX 278
EL PRADO NM
87529-0278
US

V. Phone/Fax

Practice location:
  • Phone: 575-751-9858
  • Fax: 575-751-9858
Mailing address:
  • Phone: 575-751-9858
  • Fax: 575-613-1506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberI-06235
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-06235
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: