Provider Demographics
NPI:1578070595
Name:ROBERTS, LATESA HUDSON (DHSC, MSHS, ATC)
Entity Type:Individual
Prefix:
First Name:LATESA
Middle Name:HUDSON
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:DHSC, MSHS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4871 SHIP JACK LN
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30035-3052
Mailing Address - Country:US
Mailing Address - Phone:229-220-1036
Mailing Address - Fax:
Practice Address - Street 1:4871 SHIP JACK LN
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-3052
Practice Address - Country:US
Practice Address - Phone:229-220-1036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-30
Last Update Date:2017-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0017312255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer