Healthcare Provider Details

I. General information

NPI: 1407779960
Provider Name (Legal Business Name): STACEY ROBERTS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2612 METAIRIE RD
METAIRIE LA
70001-5426
US

IV. Provider business mailing address

7510 KINGSPORT BLVD 7510 KINGSPORT BOULEVARD
NEW ORLEANS LA
70128-2114
US

V. Phone/Fax

Practice location:
  • Phone: 504-641-4302
  • Fax: 954-342-0273
Mailing address:
  • Phone: 504-641-4302
  • Fax: 954-342-0273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number193400000X
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: