Basic Information
| Provider Information | |||||||||
| NPI: | 1912921610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | HOPE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1247 | ||||||||
| Address2: | 1140 MAYBERRY DRIVE | ||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744651247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184568399 | ||||||||
| FaxNumber: | 9184568773 | ||||||||
| Practice Location | |||||||||
| Address1: | 1140 MAYBERRY DRIVE | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744644603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184568399 | ||||||||
| FaxNumber: | 9184568773 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 2133 | OK | X | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 2133 | OK | X | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.