Provider Demographics
NPI:1568504991
Name:BARTLEY ROBERTSON, ELLEN (PHD LMSW)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:BARTLEY ROBERTSON
Suffix:
Gender:F
Credentials:PHD LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 W 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-2445
Mailing Address - Country:US
Mailing Address - Phone:202-489-3945
Mailing Address - Fax:
Practice Address - Street 1:420 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2445
Practice Address - Country:US
Practice Address - Phone:202-489-3945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010938101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC23340OtherCHARTERED
DC5238OtherHEALTHRIGHT(MEDICAID MCO)
DC295627OtherAMERIGROUP
DC521066168OtherHSCSN
DC521066168OtherHSCSN
DC017338G88Medicare ID - Type UnspecifiedMEDICARE