Provider Demographics
NPI:1215129143
Name:OLMOS, LETHA SUE (LISW)
Entity type:Individual
Prefix:
First Name:LETHA
Middle Name:SUE
Last Name:OLMOS
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 CHAMA ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108
Mailing Address - Country:US
Mailing Address - Phone:505-265-0753
Mailing Address - Fax:505-268-5722
Practice Address - Street 1:540 CHAMA ST. NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108
Practice Address - Country:US
Practice Address - Phone:505-265-0753
Practice Address - Fax:505-268-5722
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-05627101YM0800X
NMI-07273104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM36628271Medicaid