Provider Demographics
NPI:1992119341
Name:OVERTON, ROBERTO (LPC)
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:
Last Name:OVERTON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 INDUSTRIAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:MI
Mailing Address - Zip Code:49013-1246
Mailing Address - Country:US
Mailing Address - Phone:269-427-7937
Mailing Address - Fax:269-427-5180
Practice Address - Street 1:870 COLFAX AVENUE
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-4843
Practice Address - Country:US
Practice Address - Phone:269-605-1277
Practice Address - Fax:269-925-6370
Is Sole Proprietor?:No
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010310101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health