Healthcare Provider Details

I. General information

NPI: 1417774019
Provider Name (Legal Business Name): ROLANDO CANALES JR. LPC ASSOCIATE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2024
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4318 WOODCOCK DR STE 120
SAN ANTONIO TX
78228-1315
US

IV. Provider business mailing address

4318 WOODCOCK DR STE 120
SAN ANTONIO TX
78228-1315
US

V. Phone/Fax

Practice location:
  • Phone: 210-571-4471
  • Fax:
Mailing address:
  • Phone: 210-571-4471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number95962
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: