Provider Demographics
NPI:1396275152
Name:ROYAL, RODERICK II
Entity type:Individual
Prefix:MR
First Name:RODERICK
Middle Name:
Last Name:ROYAL
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9418 BOOKLINE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-1428
Mailing Address - Country:US
Mailing Address - Phone:225-372-2693
Mailing Address - Fax:
Practice Address - Street 1:9428 BROOKLINE AVE STE 2
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-1428
Practice Address - Country:US
Practice Address - Phone:504-444-3329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
LA175T00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA743219772Medicaid