Provider Demographics
NPI:1275821324
Name:OLIVARRI, ROGER J JR (PHD)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:J
Last Name:OLIVARRI
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17915 BELLA LUNA WAY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257-5012
Mailing Address - Country:US
Mailing Address - Phone:210-391-9688
Mailing Address - Fax:
Practice Address - Street 1:1350 N LOOP 1604 E STE 106
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-1425
Practice Address - Country:US
Practice Address - Phone:210-614-4990
Practice Address - Fax:210-614-4991
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC2200X
TX36843103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent