MEDICARE: EMILEE ROBERTS

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	103K00000X	Behavior Analyst		IN

General Provider Information

NPI Number	:	1568149631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILEE ROBERTS

Provider Business Mailing Address
First Line	:	4753 NORTHWEST DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46835-1433
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12938 COLDWATER RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-9517
Country	:	US
Telephone Number	:	260-245-1455
Fax Number	:

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

Provider Enumeration Date	:	06/30/2023
Last Update Date	:	06/30/2023

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Directions to “ EMILEE ROBERTS ” Practice Location

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