Active NPI
Roosevelt Broach
- Mental Health Counselor
- Dallas, TX
National Provider Identifier
1083280374
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Mental Health Counselor
- License
- 79180
- Practice address
- 12959 Jupiter Rd Ste 140
Dallas, TX 75238-3200 - Phone
- (214) 221-0132
- NPI assigned
- May 27, 2021
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Mental Health Counselor | 101YM0800X | 79180 | TX | Primary |
Addresses
Primary practice location
12959 Jupiter Rd Ste 140
Dallas, TX 75238-3200
Mailing address
502 Point Royal Dr
Rockwall, TX 75087-8721
Phone (469) 688-2803
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 79180 | TX | MD | Mental Health Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1622073600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1622073600000",
"number": "1083280374",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "502 POINT ROYAL DR",
"city": "ROCKWALL",
"state": "TX",
"postal_code": "750878721",
"telephone_number": "469-688-2803"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12959 JUPITER RD STE 140",
"city": "DALLAS",
"state": "TX",
"postal_code": "752383200",
"telephone_number": "214-221-0132"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BROACH",
"first_name": "ROOSEVELT",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2021-05-27",
"last_updated": "2021-05-27",
"certification_date": "2021-05-27",
"status": "A"
},
"taxonomies": [
{
"code": "101YM0800X",
"taxonomy_group": "",
"desc": "Counselor, Mental Health",
"state": "TX",
"license": "79180",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Dallas, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 27, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.