Provider Demographics
NPI:1134807563
Name:ROBERTSON, STEVIE TYRONE
Entity type:Individual
Prefix:
First Name:STEVIE
Middle Name:TYRONE
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 S RAIFORD ST
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:NC
Mailing Address - Zip Code:27576-3242
Mailing Address - Country:US
Mailing Address - Phone:919-763-2983
Mailing Address - Fax:
Practice Address - Street 1:312 S 3RD ST
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-4544
Practice Address - Country:US
Practice Address - Phone:919-763-2983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28399101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)