Provider Demographics
NPI:1164921680
Name:ROBERTS, ADDIE (RD, LD)
Entity Type:Individual
Prefix:
First Name:ADDIE
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 SCOTTSDALE DR
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-6009
Mailing Address - Country:US
Mailing Address - Phone:214-457-0811
Mailing Address - Fax:
Practice Address - Street 1:740 SCOTTSDALE DR
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-6009
Practice Address - Country:US
Practice Address - Phone:214-457-0811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-10
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT84919133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00Z137OtherMEDICARE