=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740171974
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDON ROBERTS LMSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2025
-----------------------------------------------------
Last Update Date | 07/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 620 JOHN PAUL JONES CIR
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23708-2111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-953-6742
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 WESTOVER AVE APT 301
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23507-2311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-604-3354
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 69353
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------