Provider Demographics
NPI:1063792042
Name:OLIVARES, ROBERTA ISELA (OT)
Entity type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:ISELA
Last Name:OLIVARES
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9999 WILLOW FALLS LN
Mailing Address - Street 2:
Mailing Address - City:BROOKSHIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77423-1973
Mailing Address - Country:US
Mailing Address - Phone:832-434-8687
Mailing Address - Fax:
Practice Address - Street 1:9999 WILLOW FALLS LN
Practice Address - Street 2:
Practice Address - City:BROOKSHIRE
Practice Address - State:TX
Practice Address - Zip Code:77423-1973
Practice Address - Country:US
Practice Address - Phone:832-434-8687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-23
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106082225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist