Healthcare Provider Details

I. General information

NPI: 1720024052
Provider Name (Legal Business Name): ROGER D MCBRIDE LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 08/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7200 E INDIANA ST
EVANSVILLE IN
47715-2753
US

IV. Provider business mailing address

PO BOX 1230
EVANSVILLE IN
47706-1230
US

V. Phone/Fax

Practice location:
  • Phone: 812-476-7200
  • Fax: 812-471-4514
Mailing address:
  • Phone: 812-450-6815
  • Fax: 812-450-6822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39001552A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: