Provider Demographics
NPI:1619115433
Name:OLGUIN, TARA SUE (LPCC)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:SUE
Last Name:OLGUIN
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11930 MENAUL BLVD NE STE 221D
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-2465
Mailing Address - Country:US
Mailing Address - Phone:505-321-1345
Mailing Address - Fax:505-294-2922
Practice Address - Street 1:11930 MENAUL BLVD NE STE 221D
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-2465
Practice Address - Country:US
Practice Address - Phone:505-321-1345
Practice Address - Fax:505-294-2922
Is Sole Proprietor?:No
Enumeration Date:2009-02-02
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-0118271101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM06557023OtherMEDICAID NUMBER DD WAIVER