Provider Demographics
NPI:1730679036
Name:ROBERTSON, OLIVIA KATE (MA)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:KATE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:KATE
Other - Last Name:NYLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:151 N KALAMAZOO ST
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49097-1204
Mailing Address - Country:US
Mailing Address - Phone:269-251-8092
Mailing Address - Fax:
Practice Address - Street 1:600 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1354
Practice Address - Country:US
Practice Address - Phone:269-615-8209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst