Provider Demographics
NPI:1760677132
Name:ROBERTS, MISTY M (ARDMS,RVT)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:M
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:ARDMS,RVT
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:M
Other - Last Name:BUTTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARDMS,RVT
Mailing Address - Street 1:230 MORRIS AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63125-2733
Mailing Address - Country:US
Mailing Address - Phone:314-631-0387
Mailing Address - Fax:
Practice Address - Street 1:230 MORRIS AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-2733
Practice Address - Country:US
Practice Address - Phone:314-631-0387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
561332471S1302X, 2471V0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular Sonography
No2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography