MEDICARE: JOHN L ROBERTS LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	2060	OK

General Provider Information

NPI Number	:	1568774842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN L ROBERTS LPC

Provider Business Mailing Address
First Line	:	3800 N CLASSEN BLVD
Second Line	:	SUITE C110
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73118-2862
Country	:	US
Telephone Number	:	405-613-5230
Fax Number	:	405-525-0530

Provider Business Practice Location Address
First Line	:	3800 N CLASSEN BLVD
Second Line	:	SUITE C110
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73118-2862
Country	:	US
Telephone Number	:	405-613-5230
Fax Number	:	405-525-0530

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2010
Last Update Date	:	07/02/2010

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