MEDICARE: DR. DANNELL SPEIGHTS ROBERTS PH.D.

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	103K00000X	Behavior Analyst	160021	MS
2	103T00000X	Psychologist	47 821	MS
3	103TM1800X	Intellectual & Developmental Disabilities Psychologist	47 821	MS
4	103TS0200X	School Psychologist	47 821	MS

General Provider Information

NPI Number	:	1518127711
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DANNELL SPEIGHTS ROBERTS PH.D.

Provider Business Mailing Address
First Line	:	32 MILLBRANCH RD STE 40
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39402-1673
Country	:	US
Telephone Number	:	601-255-5264
Fax Number	:

Provider Business Practice Location Address
First Line	:	32 MILLBRANCH RD STE 40
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39402-1673
Country	:	US
Telephone Number	:	601-255-5264
Fax Number	:

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

Provider Enumeration Date	:	06/11/2008
Last Update Date	:	03/10/2025

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