Basic Information
| Provider Information | |||||||||
| NPI: | 1992119341 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OVERTON | ||||||||
| FirstName: | ROBERTO | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 INDUSTRIAL PARK RD | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490131246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694277937 | ||||||||
| FaxNumber: | 2694275180 | ||||||||
| Practice Location | |||||||||
| Address1: | 870 COLFAX AVENUE | ||||||||
| Address2: | |||||||||
| City: | BENTON HARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490224843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696051277 | ||||||||
| FaxNumber: | 2699256370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2014 | ||||||||
| LastUpdateDate: | 06/13/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6401010310 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.