Provider Demographics
NPI:1164538245
Name:ECKRICH, ROMA S
Entity Type:Individual
Prefix:DR
First Name:ROMA
Middle Name:S
Last Name:ECKRICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 TIMBERLAKE DR
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-4041
Mailing Address - Country:US
Mailing Address - Phone:817-237-1243
Mailing Address - Fax:817-237-1243
Practice Address - Street 1:2129 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76114-1924
Practice Address - Country:US
Practice Address - Phone:800-257-8715
Practice Address - Fax:800-819-1655
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23438103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX040296801Medicaid
TX860667OtherBLUE CROSS BLUE SHIELD
TX040296802Medicaid
TX680007300OtherRAIL ROAD
TX040296801Medicaid
TX040296802Medicaid