Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | 77674 | TX |
NPI | 1003386988 |
---|---|
Provider Name | Brandon Michael Roberts |
First Address | Groves, TX 77619-3516 |
Second Address | Port Arthur, TX 77642-6656 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/12/2018 |
Last Update Date | 10/01/2019 |