Provider Demographics
NPI:1639738974
Name:ROE, RICHARD TAYLOR (LCSW)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:TAYLOR
Last Name:ROE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3409 OLD CANTON RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-3236
Mailing Address - Country:US
Mailing Address - Phone:346-206-1650
Mailing Address - Fax:
Practice Address - Street 1:3000 OLD CANTON RD STE 470
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4225
Practice Address - Country:US
Practice Address - Phone:346-206-1650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX661621041C0700X
FLTPSW25071041C0700X
MSC99891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical