Healthcare Provider Details

I. General information

NPI: 1639888977
Provider Name (Legal Business Name): MS. HEATHER MARONDA ROBERTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2022
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 MAGNOLIA GARDENS WALK
MCDONOUGH GA
30253-6081
US

IV. Provider business mailing address

625 MAGNOLIA GARDENS WALK
MCDONOUGH GA
30253-6081
US

V. Phone/Fax

Practice location:
  • Phone: 678-357-2164
  • Fax:
Mailing address:
  • Phone: 678-357-2164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: