Provider Demographics
NPI:1134824030
Name:ROBERTS, TISHI M
Entity type:Individual
Prefix:
First Name:TISHI
Middle Name:M
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 1:2345 S WENTWORTH AVE UNIT 166582
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-9129
Mailing Address - Country:US
Mailing Address - Phone:312-783-4071
Mailing Address - Fax:
Practice Address - Street 1:2242 S PRINCETON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-1865
Practice Address - Country:US
Practice Address - Phone:312-218-4241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor