Provider Demographics
NPI:1649060492
Name:ROBERSONE, CARRIE
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:ROBERSONE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5021 NE 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-5079
Mailing Address - Country:US
Mailing Address - Phone:206-458-4342
Mailing Address - Fax:
Practice Address - Street 1:5329 NE MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3237
Practice Address - Country:US
Practice Address - Phone:206-458-4342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-07
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000108287172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker