1720304991 NPI number — ANDREA SUSAN ROBERTSON MSW, LICSW

Table of content: ANDREA SUSAN ROBERTSON MSW, LICSW (NPI 1720304991)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720304991 NPI number — ANDREA SUSAN ROBERTSON MSW, LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTSON
Provider First Name:
ANDREA
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720304991
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1035 SMITH AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST ST PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55118-1106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-552-7758
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8530 EAGLE POINT BLVD
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
LAKE ELMO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55042-8649
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-701-0477
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/13/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  14256 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1720304991 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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