MEDICARE: BRANDY M ROANE PHD

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	103TC0700X	Clinical Psychologist	36377	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	88610A	OTHER	TX	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881941664
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDY M ROANE PHD

Provider Business Mailing Address
First Line	:	PO BOX 99335
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76199-0335
Country	:	US
Telephone Number	:	817-735-2660
Fax Number	:

Provider Business Practice Location Address
First Line	:	855 MONTGOMERY ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-2553
Country	:	US
Telephone Number	:	817-735-2660
Fax Number	:

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

Provider Enumeration Date	:	08/10/2012
Last Update Date	:	04/12/2026

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