Basic Information
| Provider Information | |||||||||
| NPI: | 1437426426 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERSON | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | SHERYL | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MHPP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1425 W. MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WALNUT RIDGE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724761431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708865303 | ||||||||
| FaxNumber: | 8708867002 | ||||||||
| Practice Location | |||||||||
| Address1: | 1815 PLEASANT GROVE RD | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724017870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709336886 | ||||||||
| FaxNumber: | 8709339395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2011 | ||||||||
| LastUpdateDate: | 06/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 171M00000X | AR | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 185942795 | 05 | AR | MEDICAID |