Provider Demographics
NPI:1043797616
Name:ROBERTS, MELISSA ANN (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ANN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10450 72ND AVE
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-2911
Mailing Address - Country:US
Mailing Address - Phone:262-657-6453
Mailing Address - Fax:
Practice Address - Street 1:10450 72ND AVE
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-2911
Practice Address - Country:US
Practice Address - Phone:262-657-6457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-25
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI238-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst