Healthcare Provider Details

I. General information

NPI: 1558911149
Provider Name (Legal Business Name): TANYA E ROBERTS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2019
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11138 STATE BRIDGE RD
JOHNS CREEK GA
30022-7465
US

IV. Provider business mailing address

11138 STATE BRIDGE RD
JOHNS CREEK GA
30022-7465
US

V. Phone/Fax

Practice location:
  • Phone: 678-274-4936
  • Fax:
Mailing address:
  • Phone: 678-274-4936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC006263
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC006263
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: