Provider Demographics
NPI:1376581207
Name:OLIVE, TAMARA L (LPC, MED)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:L
Last Name:OLIVE
Suffix:
Gender:F
Credentials:LPC, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 S TYLER ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76901-3935
Mailing Address - Country:US
Mailing Address - Phone:325-655-7969
Mailing Address - Fax:325-655-7976
Practice Address - Street 1:219 S ABE ST
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-6305
Practice Address - Country:US
Practice Address - Phone:325-234-7174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19529101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor