Basic Information
| Provider Information | |||||||||
| NPI: | 1518188671 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | DEBORAH | ||||||||
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| Credential: | CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1595 LINKSIDE DRIVE | ||||||||
| Address2: | |||||||||
| City: | ATLANTIC BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042498893 | ||||||||
| FaxNumber: | 9042467259 | ||||||||
| Practice Location | |||||||||
| Address1: | 2348 SOUTH THIRD STREET | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042498893 | ||||||||
| FaxNumber: | 9042467259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA3317 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 700493 | 01 | FL | ACN GROUP | OTHER | 338771 | 01 | FL | WELLCARE ID | OTHER | S1829 | 01 | FL | BCBS PROVIDER # | OTHER |