Provider Demographics
NPI:1588121560
Name:ROSARIO NIEVES, EMMANUEL (PHD)
Entity type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:
Last Name:ROSARIO NIEVES
Suffix:
Gender:M
Credentials:PHD
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 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-645-0624
Mailing Address - Fax:214-645-0078
Practice Address - Street 1:5200 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7709
Practice Address - Country:US
Practice Address - Phone:469-419-9606
Practice Address - Fax:214-267-1632
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-26
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38060103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX38060OtherLICENSE