Provider Demographics
NPI:1770733487
Name:ROBERTS, JOANN (LMT)
Entity type:Individual
Prefix:
First Name:JOANN
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8200 ROGUE RIVER HWY
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-4349
Mailing Address - Country:US
Mailing Address - Phone:541-821-9299
Mailing Address - Fax:
Practice Address - Street 1:8200 ROGUE RIVER HWY
Practice Address - Street 2:950 SW 6TH. ST. SUITE #25
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-4349
Practice Address - Country:US
Practice Address - Phone:541-821-9299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLMT #15469171W00000X
ORLMT #115469174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No174400000XOther Service ProvidersSpecialist