Healthcare Provider Details

I. General information

NPI: 1710530639
Provider Name (Legal Business Name): ROBERT DEAN BROADHEAD JR. RT, MSRLS, CTRS, TRS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2019
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16201 DODD ST STE 200
VOLENTE TX
78641-6020
US

IV. Provider business mailing address

2110 RANCH ROAD 620 S UNIT 341225
LAKEWAY TX
78734-0250
US

V. Phone/Fax

Practice location:
  • Phone: 512-553-5380
  • Fax: 512-553-5380
Mailing address:
  • Phone: 512-553-5380
  • Fax: 512-532-9573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number1463
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number1463
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number82138
License Number State
# 5
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: