Provider Demographics
NPI:1851153498
Name:VAN DER LELIE, ROXANE (MFT-A)
Entity Type:Individual
Prefix:
First Name:ROXANE
Middle Name:
Last Name:VAN DER LELIE
Suffix:
Gender:F
Credentials:MFT-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 EASON ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-4822
Mailing Address - Country:US
Mailing Address - Phone:631-943-6593
Mailing Address - Fax:
Practice Address - Street 1:1206 W 43RD ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-3302
Practice Address - Country:US
Practice Address - Phone:512-710-7645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX205075106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist