Provider Demographics
NPI:1235681073
Name:ROBERTS, MICAH
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 SE WALTON BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2005 SE WALTON BOULEVARD
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-0000
Practice Address - Country:US
Practice Address - Phone:479-464-5925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-27
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator