Provider Demographics
NPI:1508267121
Name:ROBERTSON, MICHELLE (CSUDC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:CSUDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7601 S REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-4007
Mailing Address - Country:US
Mailing Address - Phone:801-233-8670
Mailing Address - Fax:801-233-8682
Practice Address - Street 1:7601 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-4007
Practice Address - Country:US
Practice Address - Phone:801-233-8670
Practice Address - Fax:801-233-8682
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9153574-6005101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1306010574Medicaid