Provider Demographics
NPI:1477640027
Name:ROBERSON, BRENDA GAIL (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:GAIL
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3719 CENTERGROVE RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-7808
Mailing Address - Country:US
Mailing Address - Phone:704-782-7996
Mailing Address - Fax:704-782-7996
Practice Address - Street 1:416 N LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-4425
Practice Address - Country:US
Practice Address - Phone:704-482-7395
Practice Address - Fax:704-482-7396
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC001260101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003061Medicaid
NC54139OtherBCBS PROVIDER NUMBER
NC2864116AOtherMEDICARE PROVIDER ID
NC6003061Medicaid