Provider Demographics
NPI:1689927675
Name:ROBINSON, TERA LYNN (MA, CCC-SLP, MED)
Entity Type:Individual
Prefix:MS
First Name:TERA
Middle Name:LYNN
Last Name:ROBINSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP, MED
Other - Prefix:MS
Other - First Name:TERA
Other - Middle Name:LYNN
Other - Last Name:ROBINSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, MED, LPC
Mailing Address - Street 1:504 N KANSAS AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LIBERAL
Mailing Address - State:KS
Mailing Address - Zip Code:67901-3346
Mailing Address - Country:US
Mailing Address - Phone:620-604-5274
Mailing Address - Fax:
Practice Address - Street 1:504 N KANSAS AVE
Practice Address - Street 2:SUITE B
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-3346
Practice Address - Country:US
Practice Address - Phone:620-604-5274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-16
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2279235Z00000X
KS2478101YP2500X
OK6106101YP2500X
OK4025235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200646380 AMedicaid
KS02020374Medicaid
OK200646380 AMedicaid