MEDICARE: BERTHA ELIA RODARTE PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	34458	TX

General Provider Information

NPI Number	:	1750605747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BERTHA ELIA RODARTE PH.D.

Provider Business Mailing Address
First Line	:	3227 GAZELLE RANGE
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78259-2268
Country	:	US
Telephone Number	:	210-787-8992
Fax Number	:

Provider Business Practice Location Address
First Line	:	403 TREELINE PARK STE 101
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-2046
Country	:	US
Telephone Number	:	210-447-6363
Fax Number	:	210-447-6364

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2010
Last Update Date	:	01/13/2022

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