Provider Demographics
NPI:1982169496
Name:MIA ROLDAN AUSTIN THERAPY PLLC
Entity Type:Organization
Organization Name:MIA ROLDAN AUSTIN THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNA-MARIE
Authorized Official - Middle Name:CHRISTINA
Authorized Official - Last Name:ROLDAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LCDC
Authorized Official - Phone:512-413-0239
Mailing Address - Street 1:6104 SHOAL CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-3130
Mailing Address - Country:US
Mailing Address - Phone:512-413-0239
Mailing Address - Fax:
Practice Address - Street 1:4101 MEDICAL PKWY STE 109
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-3724
Practice Address - Country:US
Practice Address - Phone:512-413-0239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-08
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1790130318OtherNPI TYPE 1