Provider Demographics
NPI:1194591727
Name:ROBERTS, JOSHUA ALLAN
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:ALLAN
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 1:134 GARSON LN
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-7832
Mailing Address - Country:US
Mailing Address - Phone:573-952-9055
Mailing Address - Fax:
Practice Address - Street 1:114 E COLUMBIA ST STE B5
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-3103
Practice Address - Country:US
Practice Address - Phone:573-952-9055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023004989225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist