Provider Demographics
NPI:1558456913
Name:NIEMAN, BOBBY GORDON (L P C)
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:GORDON
Last Name:NIEMAN
Suffix:
Gender:M
Credentials:L P C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 AUTUMN LEAVES TRAIL
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75060-2004
Mailing Address - Country:US
Mailing Address - Phone:972-790-0032
Mailing Address - Fax:
Practice Address - Street 1:1500 NORWOOD DR STE 205B
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-3644
Practice Address - Country:US
Practice Address - Phone:817-729-6333
Practice Address - Fax:817-282-1683
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11725101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXLP0008546Medicaid
CA221762OtherMANAGED HEALTH NETWORK
TX2253LCOtherBLUE CROSS/BLUE SHIELD