Provider Demographics
NPI:1730310459
Name:ROBERTS, MARY ANN (SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 TALLYHO DR
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36832-8624
Mailing Address - Country:US
Mailing Address - Phone:334-209-1976
Mailing Address - Fax:
Practice Address - Street 1:502 GAUTIER ST
Practice Address - Street 2:
Practice Address - City:TUSKEGEE
Practice Address - State:AL
Practice Address - Zip Code:36083-2600
Practice Address - Country:US
Practice Address - Phone:601-276-3909
Practice Address - Fax:601-276-3938
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-29
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP003757235Z00000X
AL2871235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA208585333AMedicaid