Provider Demographics
NPI:1033471925
Name:NEALE, ROBERTA (BOBBI)
Entity Type:Individual
Prefix:
First Name:ROBERTA (BOBBI)
Middle Name:
Last Name:NEALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9471 BEAUCLERC COVE LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-5430
Mailing Address - Country:US
Mailing Address - Phone:904-731-8017
Mailing Address - Fax:
Practice Address - Street 1:4035 GRANT RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-6630
Practice Address - Country:US
Practice Address - Phone:904-253-1148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1793911875281-5AOtherDCHD BADGE ID#
FLN400-736-72-648-0OtherFLORIDA DRIVERS LICENSE