Provider Demographics
NPI:1518611466
Name:ROBERSON, RACHEL ILETA
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:ILETA
Last Name:ROBERSON
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 1:972 GROUSE MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-5871
Mailing Address - Country:US
Mailing Address - Phone:901-219-2067
Mailing Address - Fax:
Practice Address - Street 1:4055 N PARK LOOP
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38152-4220
Practice Address - Country:US
Practice Address - Phone:901-678-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRBT-20-122105106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician