MEDICARE: DR. DUNIELLE THERESA ROMAN PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist
2	103TC0700X	Clinical Psychologist	5573	NC

General Provider Information

NPI Number	:	1639570922
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DUNIELLE THERESA ROMAN PSYD

Provider Business Mailing Address
First Line	:	1250 WESTERN BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-6748
Country	:	US
Telephone Number	:	910-378-9211
Fax Number	:

Provider Business Practice Location Address
First Line	:	1250 WESTERN BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-6748
Country	:	US
Telephone Number	:	910-378-9211
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2014
Last Update Date	:	06/26/2021

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