Provider Demographics
NPI:1780090662
Name:ROBINSON, MARK MATTHEW (LLMSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:MATTHEW
Last Name:ROBINSON
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 LESLIE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-3243
Mailing Address - Country:US
Mailing Address - Phone:313-491-6533
Mailing Address - Fax:
Practice Address - Street 1:4000 LESLIE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-3243
Practice Address - Country:US
Practice Address - Phone:313-491-6533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-11
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI36128361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical