Provider Demographics
NPI:1609332352
Name:ROBERTSON, CARLY BEVERLY (LM)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:BEVERLY
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 GILMORE ST
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:TX
Mailing Address - Zip Code:76574-1405
Mailing Address - Country:US
Mailing Address - Phone:512-731-9474
Mailing Address - Fax:512-352-0031
Practice Address - Street 1:1411 GILMORE ST
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:TX
Practice Address - Zip Code:76574-1405
Practice Address - Country:US
Practice Address - Phone:512-731-9474
Practice Address - Fax:512-352-0031
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX99363176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife