Provider Demographics
NPI:1871164806
Name:ROBERTS, EVAN MICHAEL (RBT)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:MICHAEL
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 LAUREL WAY
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-4811
Mailing Address - Country:US
Mailing Address - Phone:407-920-0194
Mailing Address - Fax:407-920-5346
Practice Address - Street 1:1557 PINE MARSH LOOP
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34771-7407
Practice Address - Country:US
Practice Address - Phone:407-920-5346
Practice Address - Fax:407-960-3009
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician