Provider Demographics
NPI:1477517662
Name:ROBERTS, VICKI MAXWELL (OT)
Entity Type:Individual
Prefix:MRS
First Name:VICKI
Middle Name:MAXWELL
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4412
Mailing Address - Country:US
Mailing Address - Phone:770-834-7436
Mailing Address - Fax:770-830-5954
Practice Address - Street 1:812 S PARK ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4412
Practice Address - Country:US
Practice Address - Phone:770-834-7436
Practice Address - Fax:770-830-5954
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000163225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00564539BMedicaid