Provider Demographics
NPI:1861969958
Name:OLIVER, ANGELA NICOLE (LCDC)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:NICOLE
Last Name:OLIVER
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 MIRON DR STE 110
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-7829
Mailing Address - Country:US
Mailing Address - Phone:214-908-4941
Mailing Address - Fax:
Practice Address - Street 1:325 MIRON DR STE 110
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-7829
Practice Address - Country:US
Practice Address - Phone:214-908-4941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-27
Last Update Date:2018-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11123101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)