Provider Demographics
NPI:1902983216
Name:ROBERTS, NED (BUD) OWEN (DMIN)
Entity Type:Individual
Prefix:DR
First Name:NED (BUD)
Middle Name:OWEN
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:DR
Other - First Name:NED (BUD)
Other - Middle Name:OWEN
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMIN
Mailing Address - Street 1:200 W MONROE ST
Mailing Address - Street 2:SUITE 300#20
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3997
Mailing Address - Country:US
Mailing Address - Phone:309-827-9030
Mailing Address - Fax:
Practice Address - Street 1:200 W MONROE ST
Practice Address - Street 2:SUITE 300#20
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3997
Practice Address - Country:US
Practice Address - Phone:309-827-9030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional