Provider Demographics
NPI:1699823161
Name:OLGUIN, LUCILLE JEANETTE (SLP-MS)
Entity Type:Individual
Prefix:
First Name:LUCILLE
Middle Name:JEANETTE
Last Name:OLGUIN
Suffix:
Gender:F
Credentials:SLP-MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 TRIBAL ROAD 2
Mailing Address - Street 2:
Mailing Address - City:BOSQUE FARMS
Mailing Address - State:NM
Mailing Address - Zip Code:87068-8141
Mailing Address - Country:US
Mailing Address - Phone:505-869-2698
Mailing Address - Fax:
Practice Address - Street 1:343 MAIN ST NW
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-8712
Practice Address - Country:US
Practice Address - Phone:505-865-9313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1708235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NML5889Medicaid