Provider Demographics
NPI:1952030744
Name:ROBERTS, VANESSA KOLISHA
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:KOLISHA
Last Name:ROBERTS
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 1:181 W REYNOLDS ST
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:AL
Mailing Address - Zip Code:36360-1438
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:181 W REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-1438
Practice Address - Country:US
Practice Address - Phone:334-477-4686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALRBT-22-215647103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty