Provider Demographics
NPI:1467951319
Name:ROARKE, MANDI
Entity Type:Individual
Prefix:
First Name:MANDI
Middle Name:
Last Name:ROARKE
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 1:8700 MANCHACA RD STE 706
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-5378
Mailing Address - Country:US
Mailing Address - Phone:512-537-0995
Mailing Address - Fax:
Practice Address - Street 1:8700 MANCHACA RD STE 706
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-5378
Practice Address - Country:US
Practice Address - Phone:512-537-0995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-06
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX202394106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist