Basic Information
Provider Information | |||||||||
NPI: | 1619554128 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROBERTSON | ||||||||
FirstName: | JOEL | ||||||||
MiddleName: | AARON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 420 STONE CREST AVE | ||||||||
Address2: |   | ||||||||
City: | BOWLING GREEN | ||||||||
State: | KY | ||||||||
PostalCode: | 421018868 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2707917480 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 165 NATCHEZ TRACE AVE STE 205 | ||||||||
Address2: |   | ||||||||
City: | BOWLING GREEN | ||||||||
State: | KY | ||||||||
PostalCode: | 421037947 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2707457246 | ||||||||
FaxNumber: | 2703931913 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2021 | ||||||||
LastUpdateDate: | 08/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/28/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 3015825 | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | 7100732420 | 05 | KY |   | MEDICAID | K358421 | 01 | KY | MEDICARE | OTHER |