MEDICARE: PHYLLIS ROBERTS

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	385HR2055X	Child Mental Illness Respite Care	5216	AZ

General Provider Information

NPI Number	:	1841356474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHYLLIS ROBERTS

Provider Business Mailing Address
First Line	:	1330 E SAINT ANNE AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-4437
Country	:	US
Telephone Number	:	602-305-8830
Fax Number	:

Provider Business Practice Location Address
First Line	:	1330 E SAINT ANNE AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-4437
Country	:	US
Telephone Number	:	602-305-8830
Fax Number	:

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

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	07/08/2007

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