Provider Demographics
NPI:1750344859
Name:ROBERTS, AUDREY LYNETTE (PT)
Entity type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:LYNETTE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 LEAVENWORTH ST
Mailing Address - Street 2:#402
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94133-2252
Mailing Address - Country:US
Mailing Address - Phone:415-441-2220
Mailing Address - Fax:
Practice Address - Street 1:5 BON AIR RD
Practice Address - Street 2:SUITE A105
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939-1143
Practice Address - Country:US
Practice Address - Phone:415-927-2007
Practice Address - Fax:415-927-7272
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT22384174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT223840Medicare ID - Type Unspecified