Provider Demographics
NPI:1710530639
Name:BROADHEAD, ROBERT DEAN JR (RT, MSRLS, CTRS, TRS)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:DEAN
Last Name:BROADHEAD
Suffix:JR
Gender:M
Credentials:RT, MSRLS, CTRS, TRS
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:2110 RANCH ROAD 620 S UNIT 341225
Mailing Address - Street 2:
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734-0250
Mailing Address - Country:US
Mailing Address - Phone:512-553-5380
Mailing Address - Fax:512-532-9573
Practice Address - Street 1:16201 DODD ST STE 200
Practice Address - Street 2:
Practice Address - City:VOLENTE
Practice Address - State:TX
Practice Address - Zip Code:78641-6020
Practice Address - Country:US
Practice Address - Phone:512-553-5380
Practice Address - Fax:512-553-5380
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-19
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1463101Y00000X, 225400000X
174H00000X
82138225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No174H00000XOther Service ProvidersHealth Educator
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner