Provider Demographics
NPI:1144493081
Name:ROBERTS, CARL
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32895 COASTAL HWY
Mailing Address - Street 2:
Mailing Address - City:BETHANY BEACH
Mailing Address - State:DE
Mailing Address - Zip Code:19930-3782
Mailing Address - Country:US
Mailing Address - Phone:302-539-5099
Mailing Address - Fax:302-539-8649
Practice Address - Street 1:32895 COASTAL HWY
Practice Address - Street 2:
Practice Address - City:BETHANY BEACH
Practice Address - State:DE
Practice Address - Zip Code:19930-3782
Practice Address - Country:US
Practice Address - Phone:302-539-5099
Practice Address - Fax:302-539-8649
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEMT0000128225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist