Provider Demographics
NPI:1427281716
Name:PASTORE, OLIVIA MELISSA (MA)
Entity type:Individual
Prefix:MS
First Name:OLIVIA
Middle Name:MELISSA
Last Name:PASTORE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:OLIVIA
Other - Middle Name:MELISSA
Other - Last Name:PASTORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 14572
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87191-4572
Mailing Address - Country:US
Mailing Address - Phone:505-316-2280
Mailing Address - Fax:505-316-2280
Practice Address - Street 1:6100 SEAGULL ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2500
Practice Address - Country:US
Practice Address - Phone:855-728-8476
Practice Address - Fax:855-728-8476
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-02
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM247200000X/TECHNITIOMedicaid