Provider Demographics
NPI:1366463911
Name:ROBERTSON, MARILYN (LAC)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:
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 1:300 13TH AVE W
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-4879
Mailing Address - Country:US
Mailing Address - Phone:701-227-7503
Mailing Address - Fax:701-227-7575
Practice Address - Street 1:300 13TH AVE W
Practice Address - Street 2:SUITE 1
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4879
Practice Address - Country:US
Practice Address - Phone:701-227-7503
Practice Address - Fax:701-227-7575
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1407101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54523Medicaid
ND014079OtherBCBS PIN