Provider Demographics
NPI:1114041340
Name:ROBERTS, SAMUEL J (PHD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:J
Last Name:ROBERTS
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 38326
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75238-0326
Mailing Address - Country:US
Mailing Address - Phone:214-341-3822
Mailing Address - Fax:817-424-1766
Practice Address - Street 1:601 S MAIN ST
Practice Address - Street 2:STE 216
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-5385
Practice Address - Country:US
Practice Address - Phone:817-424-5157
Practice Address - Fax:817-424-1766
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2018-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23376103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXR57215Medicare UPIN
TX00DC57Medicare ID - Type Unspecified