Provider Demographics
NPI:1790256691
Name:ROBERTS, BRYCE RICHARD (LPC)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:RICHARD
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3454 OAK ALLEY CT STE 400
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-1355
Mailing Address - Country:US
Mailing Address - Phone:419-345-6498
Mailing Address - Fax:
Practice Address - Street 1:123 22ND ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-2706
Practice Address - Country:US
Practice Address - Phone:419-475-4449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2002410101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional