Provider Demographics
NPI:1508499799
Name:ROBERSON, VICKIE LYNN (LCDC)
Entity Type:Individual
Prefix:MS
First Name:VICKIE
Middle Name:LYNN
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 WITTE RD APT 120
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77080-7636
Mailing Address - Country:US
Mailing Address - Phone:713-817-4405
Mailing Address - Fax:
Practice Address - Street 1:20910 PARK ROW DR
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449-5018
Practice Address - Country:US
Practice Address - Phone:832-306-4818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2524-6140101Y00000X
TX104865101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor