MEDICARE: MARISOL OLIVAS LMFT LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	0163541	NM

General Provider Information

NPI Number	:	1922549492
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARISOL OLIVAS LMFT LLC

Provider Business Mailing Address
First Line	:	5019 KENSINGTON WAY
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88012
Country	:	US
Telephone Number	:	505-927-8077
Fax Number	:

Provider Business Practice Location Address
First Line	:	5019 KENSINGTON WAY
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88012
Country	:	US
Telephone Number	:	505-927-8077
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. MAR OLIVAS
Credential	:	MS, LMFT
Telephone Number	:	505-927-8077

Provider Enumeration Date	:	03/16/2017
Last Update Date	:	03/16/2017

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