Healthcare Provider Details

I. General information

NPI: 1245552652
Provider Name (Legal Business Name): RANDI JO ROBERTS B.A, MHPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2010
Last Update Date: 02/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W. SECOND ST.
LONOKE AR
72086
US

IV. Provider business mailing address

PO BOX 15968
LITTLE ROCK AR
72231-5968
US

V. Phone/Fax

Practice location:
  • Phone: 501-676-3151
  • Fax: 501-676-3152
Mailing address:
  • Phone: 501-221-1843
  • Fax: 501-221-2376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: