Provider Demographics
NPI:1548414410
Name:DESROBERTS, MARK RENE (MA,LLP)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:RENE
Last Name:DESROBERTS
Suffix:
Gender:M
Credentials:MA,LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5425 COPLEY SQUARE RD
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8743
Mailing Address - Country:US
Mailing Address - Phone:810-694-1008
Mailing Address - Fax:
Practice Address - Street 1:159 KERCHEVAL AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE FARMS
Practice Address - State:MI
Practice Address - Zip Code:48236-3610
Practice Address - Country:US
Practice Address - Phone:313-640-2217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL1182507103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical