Provider Demographics
NPI:1770271157
Name:OLIVAREZ, CARL B
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:B
Last Name:OLIVAREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1651 ROCK PRAIRIE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-8652
Mailing Address - Country:US
Mailing Address - Phone:979-599-9580
Mailing Address - Fax:
Practice Address - Street 1:1651 ROCK PRAIRIE RD STE 101
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8652
Practice Address - Country:US
Practice Address - Phone:979-599-9580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10594101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty