Provider Demographics
NPI:1023370491
Name:MERCADO, OLGA T (LCDCI)
Entity Type:Individual
Prefix:
First Name:OLGA
Middle Name:T
Last Name:MERCADO
Suffix:
Gender:F
Credentials:LCDCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 26TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79411-1524
Mailing Address - Country:US
Mailing Address - Phone:806-780-8300
Mailing Address - Fax:
Practice Address - Street 1:1705 N FM 179
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416-9441
Practice Address - Country:US
Practice Address - Phone:806-797-8003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13876101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX065363601Medicaid