Basic Information
| Provider Information | |||||||||
| NPI: | 1730515875 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | CARNELL | ||||||||
| MiddleName: | DURREL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 572 | ||||||||
| Address2: | |||||||||
| City: | WARM SPRINGS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 318300572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067410840 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6135 ROOSEVELT HWY | ||||||||
| Address2: | |||||||||
| City: | WARM SPRINGS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 318302757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066555432 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2013 | ||||||||
| LastUpdateDate: | 09/20/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | PCET001966 | GA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.