1902264294 NPI number — EVELYN NICOLE ROBERTS LCSW

Table of content: EVELYN NICOLE ROBERTS LCSW (NPI 1902264294)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902264294 NPI number — EVELYN NICOLE ROBERTS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTS
Provider First Name:
EVELYN
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MITCHELL
Provider Other First Name:
EVELYN
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1902264294
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3059 EDGEWOOD CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31907-2593
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-240-0498
Provider Business Mailing Address Fax Number:
706-327-5294

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3059 EDGEWOOD CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31907-2593
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-240-0498
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/02/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)