Provider Demographics
NPI:1689785917
Name:ROBERTSON, MARY ELISABETH (MA, LP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELISABETH
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1899 20TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-5432
Mailing Address - Country:US
Mailing Address - Phone:651-633-2774
Mailing Address - Fax:
Practice Address - Street 1:7260 UNIVERSITY AVE NE
Practice Address - Street 2:SUITE 235
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-3126
Practice Address - Country:US
Practice Address - Phone:763-572-2605
Practice Address - Fax:763-572-2606
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 3004103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN489P9LAOtherBLUECROSS/BLUESHIELD