=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598622433
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHNNY OLIVAS LSAA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2026
-----------------------------------------------------
Last Update Date | 01/07/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 776 SPRUCE DR
-----------------------------------------------------
City | MESCALERO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88340-9638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-464-4432
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 776 SPRUCE DR
-----------------------------------------------------
City | MESCALERO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88340-9638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-464-4432
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | CTB-2026-0003
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------