=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598504193
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HANNAH ROBERTS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2024
-----------------------------------------------------
Last Update Date | 05/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 677 E MAIN ST
-----------------------------------------------------
City | CENTREVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49032-8524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-467-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 62137 YOUNGS PRAIRIE RD
-----------------------------------------------------
City | CONSTANTINE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49042-9677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-535-0299
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 6852094031
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------