Provider Demographics
NPI:1720304991
Name:ROBERTSON, ANDREA SUSAN (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:SUSAN
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 SMITH AVE S
Mailing Address - Street 2:
Mailing Address - City:WEST ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-1106
Mailing Address - Country:US
Mailing Address - Phone:651-552-7758
Mailing Address - Fax:
Practice Address - Street 1:8530 EAGLE POINT BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-8649
Practice Address - Country:US
Practice Address - Phone:612-701-0477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-13
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN142561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1720304991Medicaid