Provider Demographics
NPI:1295280121
Name:ROBERTS, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
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 1:955 FLORA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88007-1956
Mailing Address - Country:US
Mailing Address - Phone:505-315-4464
Mailing Address - Fax:
Practice Address - Street 1:2211 PUERTO RICO AVE
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-5529
Practice Address - Country:US
Practice Address - Phone:575-439-3270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-21
Last Update Date:2016-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-6060235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist