Provider Demographics
NPI:1144864562
Name:ROBERTS, DARYLE JOEL (RBT)
Entity type:Individual
Prefix:
First Name:DARYLE
Middle Name:JOEL
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 WHEELER AVE
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-5108
Mailing Address - Country:US
Mailing Address - Phone:774-570-0431
Mailing Address - Fax:
Practice Address - Street 1:560 BOSTON TPKE
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:MA
Practice Address - Zip Code:01545-5970
Practice Address - Country:US
Practice Address - Phone:508-443-0018
Practice Address - Fax:508-519-6436
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARBT-18-66151106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician