Healthcare Provider Details

I. General information

NPI: 1356681241
Provider Name (Legal Business Name): WOODROW ANTHONY ROEBACK III CPC, CRC, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2013
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 48TH AVE N STE 201
MYRTLE BEACH SC
29577-5418
US

IV. Provider business mailing address

1103 48TH AVE N STE 201
MYRTLE BEACH SC
29577-5418
US

V. Phone/Fax

Practice location:
  • Phone: 843-501-1099
  • Fax: 843-405-2040
Mailing address:
  • Phone: 843-501-1099
  • Fax: 843-405-2040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number9352
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCP0182
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12362
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number128746726004
License Number StateUT
# 5
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberNV20131237531
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: