Provider Demographics
NPI:1891310389
Name:ROBERTSON, ANNIE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 E KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-6609
Mailing Address - Country:US
Mailing Address - Phone:318-771-2468
Mailing Address - Fax:
Practice Address - Street 1:1316 E KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-6609
Practice Address - Country:US
Practice Address - Phone:318-224-9081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-10
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8622235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty