Basic Information
| Provider Information | |||||||||
| NPI: | 1295797710 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELIZONDO | ||||||||
| FirstName: | ROBERTO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4132 N 23RD ST | ||||||||
| Address2: | |||||||||
| City: | MCALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785044105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563183104 | ||||||||
| FaxNumber: | 9562897257 | ||||||||
| Practice Location | |||||||||
| Address1: | 4701 S SUGAR RD | ||||||||
| Address2: | |||||||||
| City: | EDINBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785397012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9562897000 | ||||||||
| FaxNumber: | 9562897257 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 19621 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 84759L | 01 | TX | BLUE SHIELD | OTHER |