Provider Demographics
NPI:1780970905
Name:ROBERTS, MARY BETH
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:BETH
Other - Last Name:RILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1316 FREDERICA STREET
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301
Mailing Address - Country:US
Mailing Address - Phone:270-686-7999
Mailing Address - Fax:270-686-8092
Practice Address - Street 1:1316 FREDERICA STREET
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301
Practice Address - Country:US
Practice Address - Phone:270-686-7999
Practice Address - Fax:270-686-8092
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health