Provider Demographics
NPI:1356681241
Name:ROEBACK, WOODROW ANTHONY III (CPC, CRC)
Entity type:Individual
Prefix:DR
First Name:WOODROW
Middle Name:ANTHONY
Last Name:ROEBACK
Suffix:III
Gender:M
Credentials:CPC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:829 W PALMDALE BLVD
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-4261
Mailing Address - Country:US
Mailing Address - Phone:714-803-0268
Mailing Address - Fax:702-255-7171
Practice Address - Street 1:241 W QUAIL DR
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-2943
Practice Address - Country:US
Practice Address - Phone:702-917-9309
Practice Address - Fax:702-255-7171
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-01
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20131237531302F00000X
NVCP0182101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No302F00000XManaged Care OrganizationsExclusive Provider Organization