Provider Demographics
NPI:1073924114
Name:ROMAN, JOHN ANTHONY II (LISW-CP)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ANTHONY
Last Name:ROMAN
Suffix:II
Gender:M
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 BROADWAY ST STE 3
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-3718
Mailing Address - Country:US
Mailing Address - Phone:843-582-7887
Mailing Address - Fax:843-800-0061
Practice Address - Street 1:917 BROADWAY ST STE 3
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-3718
Practice Address - Country:US
Practice Address - Phone:843-582-7887
Practice Address - Fax:843-800-0061
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-12
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC110701041C0700X
VA09040084961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSW1276Medicaid
SCQ51921F270Medicare PIN