Provider Demographics
NPI:1942531462
Name:DEARTH, ROBERTA
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:DEARTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25652 W COLLEEN CT
Mailing Address - Street 2:
Mailing Address - City:CHANNAHON
Mailing Address - State:IL
Mailing Address - Zip Code:60410-8638
Mailing Address - Country:US
Mailing Address - Phone:815-791-1510
Mailing Address - Fax:815-886-5983
Practice Address - Street 1:25652 W COLLEEN CT
Practice Address - Street 2:
Practice Address - City:CHANNAHON
Practice Address - State:IL
Practice Address - Zip Code:60410-8638
Practice Address - Country:US
Practice Address - Phone:815-791-1510
Practice Address - Fax:815-886-5983
Is Sole Proprietor?:No
Enumeration Date:2010-01-22
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227008582225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist