Healthcare Provider Details

I. General information

NPI: 1407370695
Provider Name (Legal Business Name): MYRANDA LYNN ROBERTS CDPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2017
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 GRANT RD STE A25
EAST WENATCHEE WA
98802-7722
US

IV. Provider business mailing address

800 W 1ST ST APT 16B
CHENEY WA
99004-8816
US

V. Phone/Fax

Practice location:
  • Phone: 509-884-9040
  • Fax: 509-884-9041
Mailing address:
  • Phone: 253-548-5422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: