Healthcare Provider Details

I. General information

NPI: 1164335493
Provider Name (Legal Business Name): MICHAEL ROBERTS III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2026
Last Update Date: 09/26/2026
Certification Date: 09/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

983 PARK PL
MACON GA
31201-2134
US

IV. Provider business mailing address

983 PARK PL
MACON GA
31201-2134
US

V. Phone/Fax

Practice location:
  • Phone: 912-695-0404
  • Fax:
Mailing address:
  • Phone: 912-695-0404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: