Basic Information
| Provider Information | |||||||||
| NPI: | 1598052045 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTSON | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 509 E ELM ST | ||||||||
| Address2: | |||||||||
| City: | SALINA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 674012353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858250541 | ||||||||
| FaxNumber: | 7858250062 | ||||||||
| Practice Location | |||||||||
| Address1: | 1421 W 8TH ST | ||||||||
| Address2: | |||||||||
| City: | WELLINGTON | ||||||||
| State: | KS | ||||||||
| PostalCode: | 671524736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6203263046 | ||||||||
| FaxNumber: | 6203265587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2011 | ||||||||
| LastUpdateDate: | 12/17/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 8094 | KS | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 200727260A | 05 | KS | MEDICAID |