Basic Information
| Provider Information | |||||||||
| NPI: | 1932472537 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTSON | ||||||||
| FirstName: | MELISSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 829 HALBERT ST | ||||||||
| Address2: | |||||||||
| City: | MALVERN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721042607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013324400 | ||||||||
| FaxNumber: | 5013324403 | ||||||||
| Practice Location | |||||||||
| Address1: | 2614 AR 27N | ||||||||
| Address2: | |||||||||
| City: | KIRBY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 71950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013218200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2012 | ||||||||
| LastUpdateDate: | 02/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | A2101187 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.