Provider Demographics
NPI:1760656854
Name:ROBERTS, DENISE MICHELLE (OTR)
Entity Type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:MICHELLE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 S KLEIN DR
Mailing Address - Street 2:
Mailing Address - City:WAUNAKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53597-1575
Mailing Address - Country:US
Mailing Address - Phone:608-849-5016
Mailing Address - Fax:608-850-6878
Practice Address - Street 1:801 S KLEIN DR
Practice Address - Street 2:
Practice Address - City:WAUNAKEE
Practice Address - State:WI
Practice Address - Zip Code:53597-1575
Practice Address - Country:US
Practice Address - Phone:608-849-5016
Practice Address - Fax:608-850-6878
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3510026174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40898100Medicaid