Healthcare Provider Details

I. General information

NPI: 1164158002
Provider Name (Legal Business Name): OLIVIA GRACE ROBERTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2022
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3860 DOBIE RD
OKEMOS MI
48864-3704
US

IV. Provider business mailing address

323 PARKWOOD DR APT R10
LANSING MI
48917-3213
US

V. Phone/Fax

Practice location:
  • Phone: 517-381-6100
  • Fax:
Mailing address:
  • Phone: 248-214-5794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7152000360
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: