Provider Demographics
NPI:1306094941
Name:OLVERA, ROBERTO (LCSW)
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:
Last Name:OLVERA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 HOPE DR. BLDG 6000
Mailing Address - Street 2:
Mailing Address - City:MT HOME AFB
Mailing Address - State:ID
Mailing Address - Zip Code:83648
Mailing Address - Country:US
Mailing Address - Phone:208-828-7520
Mailing Address - Fax:
Practice Address - Street 1:90 HOPE DR BLDG 6000
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME AFB
Practice Address - State:ID
Practice Address - Zip Code:83648
Practice Address - Country:US
Practice Address - Phone:208-828-7520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-329401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical