Provider Demographics
NPI:1225531064
Name:ROBERTS, CAROLINE N (ATC, PTA)
Entity Type:Individual
Prefix:MRS
First Name:CAROLINE
Middle Name:N
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5065 GALENA CT
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:MO
Mailing Address - Zip Code:63052-1587
Mailing Address - Country:US
Mailing Address - Phone:618-593-5820
Mailing Address - Fax:
Practice Address - Street 1:470 E LOCKWOOD AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-3194
Practice Address - Country:US
Practice Address - Phone:630-876-6286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018027218225200000X
IL160007639225200000X
IL0960042372255A2300X
MO20180272172255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant