Provider Demographics
NPI:1063142578
Name:ROBERTS, DEANNA MARIE (ATC)
Entity type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:MARIE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1471 BRIGHTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-7229
Mailing Address - Country:US
Mailing Address - Phone:814-322-8749
Mailing Address - Fax:
Practice Address - Street 1:1106 CHUCK DAWLEY BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-4183
Practice Address - Country:US
Practice Address - Phone:843-876-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1230207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000000OtherNOT A BILLING PROVIDER