Provider Demographics
NPI:1275168825
Name:ROBERSON, MICHELLE L (LMSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4727 LENNON AVE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76016-5441
Mailing Address - Country:US
Mailing Address - Phone:682-208-7438
Mailing Address - Fax:
Practice Address - Street 1:6115 CAMP BOWIE BLVD STE 220
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-5543
Practice Address - Country:US
Practice Address - Phone:469-324-9402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14224101YA0400X
TX63584101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)