Provider Demographics
NPI:1821351115
Name:ROBERTS, MICAH R
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:R
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICAH
Other - Middle Name:R
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:CLARA LUPER 615 N CLASSEN BLVD
Mailing Address - Street 2:
Mailing Address - City:OKC
Mailing Address - State:OK
Mailing Address - Zip Code:73106
Mailing Address - Country:US
Mailing Address - Phone:316-573-8821
Mailing Address - Fax:
Practice Address - Street 1:CLARA LUPER 615 N CLASSEN BLVD
Practice Address - Street 2:
Practice Address - City:OKC
Practice Address - State:OK
Practice Address - Zip Code:73106
Practice Address - Country:US
Practice Address - Phone:405-587-0430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2764235Z00000X
KS2694235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist