Provider Demographics
NPI:1295386183
Name:ROBERTS, MARKIE
Entity Type:Individual
Prefix:
First Name:MARKIE
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15935 W DODGE RD APT 1D
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68118-4059
Mailing Address - Country:US
Mailing Address - Phone:402-720-9987
Mailing Address - Fax:
Practice Address - Street 1:230 E 22ND ST STE 4
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-2661
Practice Address - Country:US
Practice Address - Phone:402-727-1592
Practice Address - Fax:402-523-5104
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE12017101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health