Provider Demographics
NPI:1558448993
Name:ROBERSON, PHYLLIS MARIE (LPC, RN)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:MARIE
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:LPC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 HILLSBOROUGH ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27603-1727
Mailing Address - Country:US
Mailing Address - Phone:919-821-0790
Mailing Address - Fax:919-861-8961
Practice Address - Street 1:401 HILLSBOROUGH ST
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27603-1727
Practice Address - Country:US
Practice Address - Phone:919-821-0790
Practice Address - Fax:919-861-8961
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6102263101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102263Medicaid
NC155657OtherNC NURSING BOARD LICENSE