Provider Demographics
NPI:1790967040
Name:ROBERTS, TAMMY J (MA, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:TAMMY
Middle Name:J
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3823 S BUSHMILL DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-8943
Mailing Address - Country:US
Mailing Address - Phone:812-325-1280
Mailing Address - Fax:
Practice Address - Street 1:3823 S BUSHMILL DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-8943
Practice Address - Country:US
Practice Address - Phone:812-325-1280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22002519235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist