=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043269087
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROXANNA LEE FORDON LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1521 GREEN OAK PL #208
-----------------------------------------------------
City | HUMBLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77339-2057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-812-8489
-----------------------------------------------------
Fax | 281-358-7788
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1521 GREEN OAK PL #208
-----------------------------------------------------
City | HUMBLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77339-2057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-812-8489
-----------------------------------------------------
Fax | 281-358-7788
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 17372
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------