Provider Demographics
NPI:1710505219
Name:ROEBACK, ANTHEA JOLIN
Entity Type:Individual
Prefix:
First Name:ANTHEA
Middle Name:JOLIN
Last Name:ROEBACK
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 1:206 SILVERBROOK LN
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:TX
Mailing Address - Zip Code:77539-6177
Mailing Address - Country:US
Mailing Address - Phone:832-319-4864
Mailing Address - Fax:
Practice Address - Street 1:105 E SHADOWBEND AVE
Practice Address - Street 2:
Practice Address - City:FRIENDSWOOD
Practice Address - State:TX
Practice Address - Zip Code:77546-3859
Practice Address - Country:US
Practice Address - Phone:713-893-3906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-19-104867106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician