Healthcare Provider Details

I. General information

NPI: 1275821324
Provider Name (Legal Business Name): ROGER J OLIVARRI JR. PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2011
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 N LOOP 1604 E STE 106
SAN ANTONIO TX
78232-1425
US

IV. Provider business mailing address

17915 BELLA LUNA WAY
SAN ANTONIO TX
78257-5012
US

V. Phone/Fax

Practice location:
  • Phone: 210-614-4990
  • Fax: 210-614-4991
Mailing address:
  • Phone: 210-391-9688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number36843
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: