Provider Demographics
NPI:1669831939
Name:ROBERTSON, THANA
Entity Type:Individual
Prefix:MS
First Name:THANA
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:THANA
Other - Middle Name:
Other - Last Name:KONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:P.O BOX 1405
Mailing Address - Street 2:STOP #1200
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92502
Mailing Address - Country:US
Mailing Address - Phone:951-955-1617
Mailing Address - Fax:951-955-1610
Practice Address - Street 1:3625 14TH ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3815
Practice Address - Country:US
Practice Address - Phone:951-955-1617
Practice Address - Fax:951-955-1610
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-16
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker