Provider Demographics
NPI:1730515875
Name:ROBERTS, CARNELL DURREL JR
Entity type:Individual
Prefix:
First Name:CARNELL
Middle Name:DURREL
Last Name:ROBERTS
Suffix:JR
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:PO BOX 572
Mailing Address - Street 2:
Mailing Address - City:WARM SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:31830-0572
Mailing Address - Country:US
Mailing Address - Phone:706-741-0840
Mailing Address - Fax:
Practice Address - Street 1:6135 ROOSEVELT HWY
Practice Address - Street 2:
Practice Address - City:WARM SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:31830-2757
Practice Address - Country:US
Practice Address - Phone:706-655-5432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-20
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET001966235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist