Provider Demographics
NPI:1174886550
Name:ROBERTS, ANASTASIA (TEACHER)
Entity type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:TEACHER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 E 19TH ST APT 2G
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-8613
Mailing Address - Country:US
Mailing Address - Phone:917-412-8605
Mailing Address - Fax:
Practice Address - Street 1:119 E 19TH ST APT 2G
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-8613
Practice Address - Country:US
Practice Address - Phone:917-412-8605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1217010174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist