=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154127298
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIJAH LANE O'LEAR CSW-A
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2025
-----------------------------------------------------
Last Update Date | 02/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1902 4TH ST STE 1
-----------------------------------------------------
City | LA GRANDE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97850-2558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-809-1669
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 WILDBIRD LN
-----------------------------------------------------
City | HILTON HEAD ISLAND
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29926-2766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-295-0219
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------