Basic Information
| Provider Information | |||||||||
| NPI: | 1538354956 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROYALTY | ||||||||
| FirstName: | ROXANE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 W UNIVERSITY AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | GEORGETOWN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786287108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128681124 | ||||||||
| FaxNumber: | 5128689894 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 W UNIVERSITY AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | GEORGETOWN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786287108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128681124 | ||||||||
| FaxNumber: | 5128689894 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2007 | ||||||||
| LastUpdateDate: | 07/18/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 61569 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1861254-01 | 05 | TX | MEDICAID |