Provider Demographics
NPI:1639723620
Name:ROBESON, AUDREY MARGARET (TLLP; RBT)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:MARGARET
Last Name:ROBESON
Suffix:
Gender:F
Credentials:TLLP; RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3014 HURON CT APT 201
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48360-2388
Mailing Address - Country:US
Mailing Address - Phone:586-747-3373
Mailing Address - Fax:
Practice Address - Street 1:1777 AXTELL DR STE 100
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4400
Practice Address - Country:US
Practice Address - Phone:248-862-1171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-28
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRBT-19-93666106S00000X
MI6362009599103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician