Healthcare Provider Details

I. General information

NPI: 1912290099
Provider Name (Legal Business Name): ROEL MARIO JOHNSON APT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2011
Last Update Date: 05/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 N GLENWOOD BLVD
TYLER TX
75702-5033
US

IV. Provider business mailing address

805 N GLENWOOD BLVD
TYLER TX
75702-5033
US

V. Phone/Fax

Practice location:
  • Phone: 903-509-0800
  • Fax: 903-509-0803
Mailing address:
  • Phone: 903-509-0800
  • Fax: 903-509-0803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number00965268
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code225CA2400X
TaxonomyAssistive Technology Practitioner Rehabilitation Counselor
License Number00965268
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: