Provider Demographics
NPI:1326791948
Name:ROBERTS, MARYANNE (MD)
Entity Type:Individual
Prefix:
First Name:MARYANNE
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4621 SEMINARY RD APT 201
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4621 SEMINARY RD APT 201
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1400
Practice Address - Country:US
Practice Address - Phone:703-939-3495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-02
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DECN-0010025405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional