Basic Information
| Provider Information | |||||||||
| NPI: | 1891826061 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLIVARES | ||||||||
| FirstName: | ROSA | ||||||||
| MiddleName: | ESMERALDA | ||||||||
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| Credential: | LCSW-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5001 N PIEDRAS ST | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799304210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155646100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 111 N HASLER BLVD STE 209 | ||||||||
| Address2: | |||||||||
| City: | BASTROP | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786023984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128076601 | ||||||||
| FaxNumber: | 5123032779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 06/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041S0200X | 41005 | TX | N | Behavioral Health & Social Service Providers | Social Worker | School | 1041C0700X | 41005 | TX | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 183874001 | 05 | TX | MEDICAID |