Provider Demographics
NPI:1699428029
Name:REVENAUGH, ROBERT LEE JR (LPC, MS)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:LEE
Last Name:REVENAUGH
Suffix:JR
Gender:M
Credentials:LPC, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26003 PINK MYRTLE CIR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77406-1732
Mailing Address - Country:US
Mailing Address - Phone:281-734-9072
Mailing Address - Fax:
Practice Address - Street 1:26003 PINK MYRTLE CIR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77406-1732
Practice Address - Country:US
Practice Address - Phone:281-734-9072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
TX79008101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist