Provider Demographics
NPI:1245369842
Name:EBALAROSA, OLGA A (LCSW)
Entity type:Individual
Prefix:
First Name:OLGA
Middle Name:A
Last Name:EBALAROSA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5801 LOWELL ST NE APT 11B
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-5900
Mailing Address - Country:US
Mailing Address - Phone:505-888-1686
Mailing Address - Fax:505-888-1683
Practice Address - Street 1:3901 LOUISIANA BLVD NE STE C
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-1448
Practice Address - Country:US
Practice Address - Phone:505-888-1686
Practice Address - Fax:505-888-1683
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-087281041C0700X
NMI 050211041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM6974228Medicaid
NM69603324Medicaid