=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912460379
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AUDREY OLIVER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2019
-----------------------------------------------------
Last Update Date | 07/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 PERKINS DR STE B
-----------------------------------------------------
City | LAS CRUCES
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88005-3248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-652-3155
-----------------------------------------------------
Fax | 575-652-4104
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1015 CRAIG CT
-----------------------------------------------------
City | LAS CRUCES
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88001-2552
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-642-6207
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 216894
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------