Provider Demographics
NPI:1194369355
Name:ROBINSON, MARY ALICE (MA, MS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:ROBINSON
Suffix:
Gender:F
Credentials:MA, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4531 DELEON ST STE 206
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1280
Mailing Address - Country:US
Mailing Address - Phone:239-277-0646
Mailing Address - Fax:
Practice Address - Street 1:4531 DELEON ST STE 206
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1280
Practice Address - Country:US
Practice Address - Phone:239-277-0646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT000203101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health