MEDICARE: LATESSA L ROBY LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	56311	TX
2	1041C0700X	Clinical Social Worker	CSW005885	GA

General Provider Information

NPI Number	:	1013366319
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATESSA L ROBY LCSW

Provider Business Mailing Address
First Line	:	3645 MARKETPLACE BLVD
Second Line	:	#130-198
City	:	ATLANTA
State	:	GA
Zip	:	30344-5747
Country	:	US
Telephone Number	:	402-517-0289
Fax Number	:

Provider Business Practice Location Address
First Line	:	3645 MARKETPLACE BLVD # 130-198
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30344-5747
Country	:	US
Telephone Number	:	402-517-0289
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2016
Last Update Date	:	07/21/2022

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