Provider Demographics
NPI:1770931446
Name:ROBERSON, TRACIE JACQUELINE (LPC)
Entity type:Individual
Prefix:MRS
First Name:TRACIE
Middle Name:JACQUELINE
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 761389
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-1389
Mailing Address - Country:US
Mailing Address - Phone:210-504-8329
Mailing Address - Fax:210-855-9942
Practice Address - Street 1:1485 N ELLISON DR
Practice Address - Street 2:SITE#115
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-4001
Practice Address - Country:US
Practice Address - Phone:210-683-6329
Practice Address - Fax:210-855-9942
Is Sole Proprietor?:No
Enumeration Date:2016-06-02
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX71272101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health