=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588465900
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE LYNN ROBERTS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2025
-----------------------------------------------------
Last Update Date | 03/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4352 W SYLVANIA AVE
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43623-3463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-561-5433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1716 N ELM ST.
-----------------------------------------------------
City | GRAYTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-345-4929
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Registered Nurse
-----------------------------------------------------
License Number | 277279
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------