Provider Demographics
NPI:1942767355
Name:ADAMS, ROOSEVELT JR (PASTORAL COUNSELOR)
Entity Type:Individual
Prefix:
First Name:ROOSEVELT
Middle Name:
Last Name:ADAMS
Suffix:JR
Gender:M
Credentials:PASTORAL COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 29735
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-0735
Mailing Address - Country:US
Mailing Address - Phone:210-789-0588
Mailing Address - Fax:210-271-9414
Practice Address - Street 1:1852 LOCKHILL SELMA RD STE 108
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213-1500
Practice Address - Country:US
Practice Address - Phone:210-789-0588
Practice Address - Fax:210-271-9414
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-22
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX09203449OtherTEXAS DRIVER'S LICENSE