Provider Demographics
NPI:1992105944
Name:ROBERTS, ALICIA ELLEN
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:ELLEN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:E
Other - Last Name:WHITTINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:501 S ABILENE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-6380
Mailing Address - Country:US
Mailing Address - Phone:575-359-3707
Mailing Address - Fax:
Practice Address - Street 1:501 S ABILENE AVE
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-6380
Practice Address - Country:US
Practice Address - Phone:575-359-3707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5575235Z00000X, 2355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist