Provider Demographics
NPI:1205533262
Name:ROBERSON, EDMUND MAURICE (LPCA)
Entity type:Individual
Prefix:
First Name:EDMUND
Middle Name:MAURICE
Last Name:ROBERSON
Suffix:
Gender:M
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:952 OLD SEVEN MILE PIKE
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-8818
Mailing Address - Country:US
Mailing Address - Phone:502-345-6732
Mailing Address - Fax:
Practice Address - Street 1:213 MIDLAND BLVD
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-7791
Practice Address - Country:US
Practice Address - Phone:502-647-0154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY278975101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health