Provider Demographics
NPI:1831587534
Name:ROBERTS, CHARISSA
Entity type:Individual
Prefix:
First Name:CHARISSA
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 1:2131 FOXGLOVE DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-4775
Mailing Address - Country:US
Mailing Address - Phone:317-771-8573
Mailing Address - Fax:
Practice Address - Street 1:7393 BUSINESS CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-9289
Practice Address - Country:US
Practice Address - Phone:317-742-5055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-03
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005423A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist