Provider Demographics
NPI:1427780089
Name:ROBERTS, KRISTIE DAWN
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:DAWN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 BEECH LN
Mailing Address - Street 2:
Mailing Address - City:ROAN MOUNTAIN
Mailing Address - State:TN
Mailing Address - Zip Code:37687-3383
Mailing Address - Country:US
Mailing Address - Phone:423-943-8673
Mailing Address - Fax:
Practice Address - Street 1:301 S WATAUGA AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-3546
Practice Address - Country:US
Practice Address - Phone:423-542-6512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3726225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist