Provider Demographics
NPI:1497887269
Name:ROBERTS, SALLY ANN
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:ANN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:SALLY
Other - Middle Name:ANN
Other - Last Name:PLATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:401 PARIS AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-4440
Mailing Address - Country:US
Mailing Address - Phone:815-398-1634
Mailing Address - Fax:
Practice Address - Street 1:401 PARIS AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-4440
Practice Address - Country:US
Practice Address - Phone:815-398-1634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490018651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10132130OtherBCBS
IL149001865OtherSTATE LICENSE