Provider Demographics
NPI:1396758579
Name:ROBERTS, TAMARA (PHD)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 SAINT MATTHEWS AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-3137
Mailing Address - Country:US
Mailing Address - Phone:502-721-0435
Mailing Address - Fax:502-721-0436
Practice Address - Street 1:159 SAINT MATTHEWS AVE STE 3
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-3137
Practice Address - Country:US
Practice Address - Phone:502-721-0435
Practice Address - Fax:502-721-0436
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY129250103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0046719Medicare ID - Type Unspecified