Provider Demographics
NPI:1821563677
Name:ROBERTS, AMANDA KRISTINE (ATC)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:KRISTINE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:KRISTINE
Other - Last Name:OBERLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:244 DERBY CT
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-1438
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1493 HIGHWAY 92
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30102
Practice Address - Country:US
Practice Address - Phone:716-515-8296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0024102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty