Basic Information
| Provider Information | |||||||||
| NPI: | 1861797227 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERSON | ||||||||
| FirstName: | DUSTIN | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PROVISIONAL L.P.E | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 DONS WAY | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719136478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016247111 | ||||||||
| FaxNumber: | 5016205109 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 DONS WAY | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719136478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016247111 | ||||||||
| FaxNumber: | 5016205109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2011 | ||||||||
| LastUpdateDate: | 02/24/2012 | ||||||||
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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 | 101YM0800X | 10-57AE-PL | AR | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 10-50 AE-PL | AR | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 12-02 AE-PL | AR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.