Basic Information
| Provider Information | |||||||||
| NPI: | 1609231075 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERSON | ||||||||
| FirstName: | TANISHA | ||||||||
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| Credential: | MHPP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20400 COLONEL GLENN RD | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722105323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018215500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 20400 COLONEL GLENN RD | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722105323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018215500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2015 | ||||||||
| LastUpdateDate: | 12/29/2015 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.