=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295797710
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERTO ELIZONDO JR. LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4701 S SUGAR RD
-----------------------------------------------------
City | EDINBURG
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78539-7012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-289-7000
-----------------------------------------------------
Fax | 956-289-7257
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4132 N 23RD ST
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78504-4105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-318-3104
-----------------------------------------------------
Fax | 956-289-7257
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 19621
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------