Provider Demographics
NPI:1467999854
Name:DELOACH, ROBERTA KATRINA
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:KATRINA
Last Name:DELOACH
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 1:1655 CENTERVIEW DR APT 1615
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-5952
Mailing Address - Country:US
Mailing Address - Phone:912-247-0845
Mailing Address - Fax:
Practice Address - Street 1:1655 CENTERVIEW DR APT 1615
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5952
Practice Address - Country:US
Practice Address - Phone:912-247-0845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-24
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC011037101YP2500X
GAAPC005345101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional