Provider Demographics
NPI:1386808848
Name:ROBERTS, MARY ELLEN (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1612 NW 184TH ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-0607
Mailing Address - Country:US
Mailing Address - Phone:405-642-7999
Mailing Address - Fax:405-562-4598
Practice Address - Street 1:1612 NW 184TH ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73012-0607
Practice Address - Country:US
Practice Address - Phone:405-642-7999
Practice Address - Fax:405-562-4598
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-14
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK30471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK10OtherBEHAVIORAL HEALTH & SOCIAL SERVICE PROVIDERS