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General NPI Number Information
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NPI Number | 1558865386
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Entity Type | Individual
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Provider Name | BONI-LOU TAMARA ROBERTS CADC II
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Gender | Female
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Dates
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Enumeration Date | 03/19/2018
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Last Update Date | 03/19/2018
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Provider Practice Location Address
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Address Line | 2402 TIFT AVE N STE 202
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City | TIFTON
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State | GA
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Zip | 31794-1885
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Country | US
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Telephone | 229-382-7898
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Fax | 229-386-5818
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Provider Business Mailing Address
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Address Line | 2503 CANTERBURY CT APT N15
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City | ALBANY
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State | GA
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Zip | 31707-6636
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Country | US
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Telephone | 229-344-7392
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 0907
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License Number State | GA
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