Provider Demographics
NPI:1306946652
Name:MCNELLIE, ROGER BRUCE (PHD,MSSW,LCSW,LPC)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:BRUCE
Last Name:MCNELLIE
Suffix:
Gender:M
Credentials:PHD,MSSW,LCSW,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5922 PRINCESS LN
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-7718
Mailing Address - Country:US
Mailing Address - Phone:936-560-9437
Mailing Address - Fax:936-560-9437
Practice Address - Street 1:5922 PRINCESS LN
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-7718
Practice Address - Country:US
Practice Address - Phone:936-560-9437
Practice Address - Fax:936-560-9437
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5808101YP2500X
TXS10741041C0700X
TX106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist