Provider Demographics
NPI:1083280374
Name:BROACH, ROOSEVELT
Entity Type:Individual
Prefix:
First Name:ROOSEVELT
Middle Name:
Last Name:BROACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 POINT ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-8721
Mailing Address - Country:US
Mailing Address - Phone:469-688-2803
Mailing Address - Fax:
Practice Address - Street 1:12959 JUPITER RD STE 140
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75238-3200
Practice Address - Country:US
Practice Address - Phone:214-221-0132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX79180101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health