Provider Demographics
NPI:1386754190
Name:ROBERTS, AMY FULLER (MS,LPC)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:FULLER
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MS,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 WOLF LN
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76705-6169
Mailing Address - Country:US
Mailing Address - Phone:254-867-8206
Mailing Address - Fax:254-867-8206
Practice Address - Street 1:1300 AUSTIN AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76701-1830
Practice Address - Country:US
Practice Address - Phone:254-749-5953
Practice Address - Fax:254-867-8206
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15750101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
271732OtherCOMPSYCH
TX7039LCOtherBLUE CROSS BLUE SHIELD TX