Healthcare Provider Details

I. General information

NPI: 1174635379
Provider Name (Legal Business Name): RON L ROBERTS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 S FLEISHEL AVE
TYLER TX
75701-2012
US

IV. Provider business mailing address

606 S FLEISHEL AVE STE 204
TYLER TX
75701-2012
US

V. Phone/Fax

Practice location:
  • Phone: 903-581-0933
  • Fax: 903-581-3977
Mailing address:
  • Phone: 903-581-0933
  • Fax: 903-581-3977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number14775
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number15103
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: