Provider Demographics
NPI:1992293815
Name:ROBERTS, RONIESHA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:RONIESHA
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:277 CUBA ST
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:38635-2102
Mailing Address - Country:US
Mailing Address - Phone:662-291-0031
Mailing Address - Fax:
Practice Address - Street 1:277 CUBA ST
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:38635-2102
Practice Address - Country:US
Practice Address - Phone:662-291-0031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN121854201OtherDRIVERS LICENSE
TN121854201OtherDRIVERS LICENSE