Basic Information
Provider Information | |||||||||
NPI: | 1750432084 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROBERTS | ||||||||
FirstName: | ALECIA | ||||||||
MiddleName: | B | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 823 DAVIDSON DR NW | ||||||||
Address2: |   | ||||||||
City: | CONCORD | ||||||||
State: | NC | ||||||||
PostalCode: | 280254351 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7047869297 | ||||||||
FaxNumber: | 7047931388 | ||||||||
Practice Location | |||||||||
Address1: | 21 SAND DOLLAR CT | ||||||||
Address2: |   | ||||||||
City: | CAROLINA SHORES | ||||||||
State: | NC | ||||||||
PostalCode: | 284672500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8433600822 | ||||||||
FaxNumber: | 9106634050 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/15/2007 | ||||||||
LastUpdateDate: | 09/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | 1039 | NC | Y |   | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 1039 | 01 | NC | LICENSE NUMBER | OTHER |