MEDICARE: MR. GEORGE LEROY ROBERTS LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	003114	MO

General Provider Information

NPI Number	:	1003962168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GEORGE LEROY ROBERTS LCSW

Provider Business Mailing Address
First Line	:	932 BEACH AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63112-2020
Country	:	US
Telephone Number	:	314-721-2180
Fax Number	:

Provider Business Practice Location Address
First Line	:	932 BEACH AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63112-2020
Country	:	US
Telephone Number	:	314-721-2180
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	07/08/2007

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