Healthcare Provider Details

I. General information

NPI: 1134395460
Provider Name (Legal Business Name): CARMEN ROBERTS OT/L, CHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2008
Last Update Date: 05/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 W ANTHONY DR
URBANA IL
61802-7431
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2500
US

V. Phone/Fax

Practice location:
  • Phone: 217-326-2900
  • Fax: 217-326-2996
Mailing address:
  • Phone: 217-326-2911
  • Fax: 217-326-2996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056002127
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: