Provider Demographics
NPI:1134686652
Name:ROBERTSON, MARCELLA ANN (LAC)
Entity Type:Individual
Prefix:MRS
First Name:MARCELLA
Middle Name:ANN
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:REDFIELD
Mailing Address - State:SD
Mailing Address - Zip Code:57469-1133
Mailing Address - Country:US
Mailing Address - Phone:605-450-6031
Mailing Address - Fax:
Practice Address - Street 1:1005 W 1ST ST STE 2
Practice Address - Street 2:
Practice Address - City:REDFIELD
Practice Address - State:SD
Practice Address - Zip Code:57469-1535
Practice Address - Country:US
Practice Address - Phone:605-450-6031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)