Provider Demographics
NPI:1174635379
Name:ROBERTS, RON L (MS)
Entity Type:Individual
Prefix:MR
First Name:RON
Middle Name:L
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 S FLEISHEL AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2012
Mailing Address - Country:US
Mailing Address - Phone:903-581-0933
Mailing Address - Fax:903-581-3977
Practice Address - Street 1:606 S FLEISHEL AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2012
Practice Address - Country:US
Practice Address - Phone:903-581-0933
Practice Address - Fax:903-581-3977
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14775101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX95882905Medicaid
99-0414366OtherIRS