Provider Demographics
NPI:1407480122
Name:CLESEN, ROBIN
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:
Last Name:CLESEN
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 1:2415 PEACHTREE RD
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-8533
Mailing Address - Country:US
Mailing Address - Phone:770-335-4516
Mailing Address - Fax:
Practice Address - Street 1:2415 PEACHTREE RD
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-8533
Practice Address - Country:US
Practice Address - Phone:770-335-4516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32814103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool