Provider Demographics
NPI:1326558842
Name:ROBERTS, BENJAMIN III
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:ROBERTS
Suffix:III
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 1:462 RODNEY ST
Mailing Address - Street 2:
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-3546
Mailing Address - Country:US
Mailing Address - Phone:615-200-3007
Mailing Address - Fax:
Practice Address - Street 1:312 N DURHAM AVE
Practice Address - Street 2:
Practice Address - City:GALLATIN
Practice Address - State:TN
Practice Address - Zip Code:37066-2756
Practice Address - Country:US
Practice Address - Phone:615-200-3007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3960101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional