Provider Demographics
NPI:1235278896
Name:ROBERTS, VICKI JUNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:VICKI
Middle Name:JUNE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1778 CENTURY BLVD NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-3398
Mailing Address - Country:US
Mailing Address - Phone:404-638-6650
Mailing Address - Fax:404-638-6651
Practice Address - Street 1:1778 CENTURY BLVD NE
Practice Address - Street 2:SUITE A
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-3398
Practice Address - Country:US
Practice Address - Phone:404-638-6650
Practice Address - Fax:404-638-6651
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001865103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000669149BMedicaid
GA68BBFPLMedicare ID - Type Unspecified