Provider Demographics
NPI:1629591458
Name:ROBERSON, AUSTIN
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:ROBERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3321 NEIGHBORS LN
Mailing Address - Street 2:
Mailing Address - City:DEL CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73115-1964
Mailing Address - Country:US
Mailing Address - Phone:405-922-0201
Mailing Address - Fax:
Practice Address - Street 1:3321 NEIGHBORS LN
Practice Address - Street 2:
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-1964
Practice Address - Country:US
Practice Address - Phone:405-821-5268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-24
Last Update Date:2017-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health