Provider Demographics
NPI:1669519575
Name:WORTHEN, ROGER BRENT (PHD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:BRENT
Last Name:WORTHEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4910 AIRPORT AVE
Mailing Address - Street 2:BUILDING D
Mailing Address - City:ROSENBERG
Mailing Address - State:TX
Mailing Address - Zip Code:77471-5759
Mailing Address - Country:US
Mailing Address - Phone:281-239-1369
Mailing Address - Fax:281-239-0828
Practice Address - Street 1:711 S 11TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77469-3361
Practice Address - Country:US
Practice Address - Phone:281-342-0090
Practice Address - Fax:281-341-9388
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21032103T00000X, 103TM1800X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86668AOtherBCBS
TX82686PMedicare ID - Type UnspecifiedTEXANA GROUP