Basic Information
| Provider Information | |||||||||
| NPI: | 1871716209 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTSON | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROBERTSON | ||||||||
| OtherFirstName: | BECKY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS LPC | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1320 S COMMERCE ST TRLR 88 | ||||||||
| Address2: | |||||||||
| City: | ARDMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734015506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803718438 | ||||||||
| FaxNumber: | 5807957444 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 PLAZA | ||||||||
| Address2: | |||||||||
| City: | MADILL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734462248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5807957439 | ||||||||
| FaxNumber: | 5807957444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2521 | OK | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 14789 | TX | N | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.