Provider Demographics
NPI:1700950359
Name:ROBERTS, GRETCHEN (M OT)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:M OT
Other - Prefix:
Other - First Name:GRETCHEN
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:M OT
Mailing Address - Street 1:311 COOPER RD
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-4976
Mailing Address - Country:US
Mailing Address - Phone:678-205-5437
Mailing Address - Fax:678-377-7950
Practice Address - Street 1:311 COOPER RD
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-4976
Practice Address - Country:US
Practice Address - Phone:678-205-5437
Practice Address - Fax:678-377-7950
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003118225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist