Provider Demographics
NPI:1164786828
Name:ROBERTS, MELANIE R
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:R
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:R
Other - Last Name:EDMONDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5715 W ALEXANDER RD STE 115
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-2815
Mailing Address - Country:US
Mailing Address - Phone:702-757-8720
Mailing Address - Fax:702-974-4677
Practice Address - Street 1:5715 W ALEXANDER RD STE 115
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-2815
Practice Address - Country:US
Practice Address - Phone:702-757-5720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1760596480Medicaid