Provider Demographics
NPI:1548702749
Name:ROBERTSON, EVANGELA
Entity type:Individual
Prefix:
First Name:EVANGELA
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1651 E 70TH ST # 259
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5115
Mailing Address - Country:US
Mailing Address - Phone:318-734-9051
Mailing Address - Fax:
Practice Address - Street 1:1651 E 70TH ST # 259
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5115
Practice Address - Country:US
Practice Address - Phone:318-734-9051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-06
Last Update Date:2016-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician