Provider Demographics
NPI:1568899227
Name:ROBERTS, ALISA (AMFT)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4117 A BEDFORD CIR
Mailing Address - Street 2:
Mailing Address - City:HILL AIR FORCE BASE
Mailing Address - State:UT
Mailing Address - Zip Code:84056
Mailing Address - Country:US
Mailing Address - Phone:801-678-8294
Mailing Address - Fax:
Practice Address - Street 1:1181 CHRISTMAS BOX LANE
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404
Practice Address - Country:US
Practice Address - Phone:801-425-0227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8791054-3904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist