Provider Demographics
NPI:1588278907
Name:MEEKS, ROBERTA MICHELLE (MT)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:MICHELLE
Last Name:MEEKS
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1046 MAINSTREET LAKE DR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30088-2348
Mailing Address - Country:US
Mailing Address - Phone:404-660-1830
Mailing Address - Fax:
Practice Address - Street 1:1046 MAINSTREET LAKE DR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30088-2348
Practice Address - Country:US
Practice Address - Phone:404-660-1830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT000249225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist