Provider Demographics
NPI:1124590153
Name:ROBERTSON, LEAH CATHERINE (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:CATHERINE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:923 E CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-1431
Mailing Address - Country:US
Mailing Address - Phone:217-820-0734
Mailing Address - Fax:
Practice Address - Street 1:2035 W ILES AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4192
Practice Address - Country:US
Practice Address - Phone:217-679-5080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-18-34006103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst