Provider Demographics
NPI:1336824341
Name:ROBERTSON, MICHAEL ANTHONY
Entity Type:Individual
Prefix:PROF
First Name:MICHAEL
Middle Name:ANTHONY
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 1:15700 BIG SPRING DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-9137
Mailing Address - Country:US
Mailing Address - Phone:346-514-8821
Mailing Address - Fax:
Practice Address - Street 1:15700 BIG SPRING DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-9137
Practice Address - Country:US
Practice Address - Phone:346-514-8821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty