Healthcare Provider Details

I. General information

NPI: 1912812348
Provider Name (Legal Business Name): MADISON ROBERTS MS, LPC ASSOCIATE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4841 MERLOT AVE UNIT 420
GRAPEVINE TX
76051-7382
US

IV. Provider business mailing address

4841 MERLOT AVE UNIT 420
GRAPEVINE TX
76051-7382
US

V. Phone/Fax

Practice location:
  • Phone: 817-809-8399
  • Fax:
Mailing address:
  • Phone: 817-809-8399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number102996
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: