Provider Demographics
NPI:1104572437
Name:ROMAN, BRENDA ENID
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:ENID
Last Name:ROMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:ENID
Other - Last Name:VEGA RIVERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4003 W STAN SCHLUETER LOOP STE 201
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-6119
Mailing Address - Country:US
Mailing Address - Phone:254-630-1578
Mailing Address - Fax:254-267-1091
Practice Address - Street 1:4003 W STAN SCHLUETER LOOP STE 201
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-6119
Practice Address - Country:US
Practice Address - Phone:254-630-1578
Practice Address - Fax:254-267-1091
Is Sole Proprietor?:No
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-22-204112106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician