MEDICARE: MR. RONNIE ROBERTS CMSW

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	CSW0000005411	TN

General Provider Information

NPI Number	:	1568486520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RONNIE ROBERTS CMSW

Provider Business Mailing Address
First Line	:	105 WOODLAND RD
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-5469
Country	:	US
Telephone Number	:	423-926-1171
Fax Number	:	423-979-3447

Provider Business Practice Location Address
First Line	:	105 WOODLAND RD
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-5469
Country	:	US
Telephone Number	:	423-926-1171
Fax Number	:	423-979-3447

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

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	07/08/2007

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