Provider Demographics
NPI:1669030896
Name:ROBERTS, NICOLE BREANN
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:BREANN
Last Name:ROBERTS
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 1:5302 HIBISCUS DR
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-3710
Mailing Address - Country:US
Mailing Address - Phone:916-477-9985
Mailing Address - Fax:
Practice Address - Street 1:3101 SUNSET BLVD STE 1A
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-3097
Practice Address - Country:US
Practice Address - Phone:916-773-0211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician