Provider Demographics
NPI:1275842254
Name:LIVE, LLC
Entity Type:Organization
Organization Name:LIVE, LLC
Other - Org Name:LIVE COUNSELING & MEDIATION
Other - Org Type:Other Name
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:OLLOM
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:505-717-7227
Mailing Address - Street 1:PO BOX 35144
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87176-5144
Mailing Address - Country:US
Mailing Address - Phone:505-717-7227
Mailing Address - Fax:505-404-7897
Practice Address - Street 1:4004 CARLISLE BLVD NE STE C6
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4565
Practice Address - Country:US
Practice Address - Phone:505-717-7227
Practice Address - Fax:505-404-7897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-24
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-058231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM49626019Medicaid