Healthcare Provider Details

I. General information

NPI: 1255315693
Provider Name (Legal Business Name): MICHAEL A ROMAN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4242 MEDICAL DR STE 7100
SAN ANTONIO TX
78229-5397
US

IV. Provider business mailing address

4242 MEDICAL DR STE 7100
SAN ANTONIO TX
78229-5397
US

V. Phone/Fax

Practice location:
  • Phone: 210-342-1906
  • Fax: 210-570-8203
Mailing address:
  • Phone: 210-342-1906
  • Fax: 210-570-8203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number24435
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number24435
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number30235
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number24435
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: