Provider Demographics
NPI:1376076588
Name:ROBERTS, JUANITA
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 SHAMROCK DR
Mailing Address - Street 2:2727 SHAMROCK DRIVE
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-2215
Mailing Address - Country:US
Mailing Address - Phone:704-563-0886
Mailing Address - Fax:704-563-9731
Practice Address - Street 1:2727 SHAMROCK DR
Practice Address - Street 2:2727 SHAMROCK DRIVE
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-2215
Practice Address - Country:US
Practice Address - Phone:704-563-0886
Practice Address - Fax:704-563-9731
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6143225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1386764249Medicaid
1Medicare PIN