Provider Demographics
NPI:1558370122
Name:OLLOM, MICHAEL (LISW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:OLLOM
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 EL CEDRO RD
Mailing Address - Street 2:
Mailing Address - City:TIJERAS
Mailing Address - State:NM
Mailing Address - Zip Code:87059-7429
Mailing Address - Country:US
Mailing Address - Phone:505-565-1619
Mailing Address - Fax:505-565-1620
Practice Address - Street 1:872 S CAMINO DEL PUEBLO
Practice Address - Street 2:
Practice Address - City:BERNALILLO
Practice Address - State:NM
Practice Address - Zip Code:87004-5927
Practice Address - Country:US
Practice Address - Phone:505-867-2383
Practice Address - Fax:505-867-7293
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLISW - I-058231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM11282053Medicaid