Provider Demographics
NPI:1013533421
Name:ROBERTSON, EMILY ELLEN
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ELLEN
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:ELLEN
Other - Last Name:ELDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3518 W HILL ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30021-1203
Mailing Address - Country:US
Mailing Address - Phone:770-519-8150
Mailing Address - Fax:
Practice Address - Street 1:2010 MONTREAL RD
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5203
Practice Address - Country:US
Practice Address - Phone:770-609-8777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-20-124134106S00000X
GA1-22-58820103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician