1740221340 NPI number — S ROLAND OLIVER LCSW

Table of content: S ROLAND OLIVER LCSW (NPI 1740221340)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740221340 NPI number — S ROLAND OLIVER LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLIVER
Provider First Name:
S
Provider Middle Name:
ROLAND
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740221340
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2317 BONANZA CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH JORDAN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84095-3103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-254-0220
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4250 W 5415 S
Provider Second Line Business Practice Location Address:
FL 3
Provider Business Practice Location Address City Name:
KEARNS
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84118-4303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-969-4181
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  128688-3501 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: BC-3001 . This is a "BCBS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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