Provider Demographics
NPI:1336645506
Name:ROBERTS, TAMMY JEAN (RBT)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:JEAN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31147 BEACHWALK DR APT 101
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-1451
Mailing Address - Country:US
Mailing Address - Phone:313-300-4273
Mailing Address - Fax:
Practice Address - Street 1:31147 BEACHWALK DR APT 101
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-1451
Practice Address - Country:US
Practice Address - Phone:313-300-4273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI52749106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician