Provider Demographics
NPI:1336710177
Name:OLIVAS, IRMA ISELA
Entity Type:Individual
Prefix:
First Name:IRMA
Middle Name:ISELA
Last Name:OLIVAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6111 ALAMEDA AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-4734
Mailing Address - Country:US
Mailing Address - Phone:915-772-2045
Mailing Address - Fax:915-772-7275
Practice Address - Street 1:6111 ALAMEDA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-4734
Practice Address - Country:US
Practice Address - Phone:915-772-2045
Practice Address - Fax:915-772-7275
Is Sole Proprietor?:No
Enumeration Date:2021-07-02
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12257101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX29013744Medicaid