Provider Demographics
NPI:1962688499
Name:ROBERTS, LESLIE JO (MSH, RD, LD)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:JO
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MSH, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 FRAN LN
Mailing Address - Street 2:APT. #27
Mailing Address - City:RINGGOLD
Mailing Address - State:GA
Mailing Address - Zip Code:30736-2669
Mailing Address - Country:US
Mailing Address - Phone:678-538-8461
Mailing Address - Fax:
Practice Address - Street 1:1109 BURLEYSON RD
Practice Address - Street 2:SUITE 203
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-3094
Practice Address - Country:US
Practice Address - Phone:706-272-6079
Practice Address - Fax:678-272-6053
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003066133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered