Provider Demographics
NPI:1174233449
Name:ROBERTS, LARALEIGH (ATC)
Entity type:Individual
Prefix:
First Name:LARALEIGH
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4182 WILD DUCK DR
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39335-9515
Mailing Address - Country:US
Mailing Address - Phone:601-604-9983
Mailing Address - Fax:
Practice Address - Street 1:4182 WILD DUCK DR
Practice Address - Street 2:
Practice Address - City:LAUDERDALE
Practice Address - State:MS
Practice Address - Zip Code:39335-9515
Practice Address - Country:US
Practice Address - Phone:601-604-9983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-28
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AL28792255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program