Provider Demographics
NPI:1720251580
Name:ROBERTSON, BROOKE E (LAPC)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:E
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2283 WRIGHTSBORO RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-4717
Mailing Address - Country:US
Mailing Address - Phone:706-922-3252
Mailing Address - Fax:706-922-3253
Practice Address - Street 1:2283 WRIGHTSBORO RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-4717
Practice Address - Country:US
Practice Address - Phone:706-922-3252
Practice Address - Fax:706-922-3253
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-11
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC001959101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000606317BMedicaid
GAGRP2010Medicare PIN