Provider Demographics
NPI:1902980923
Name:ROBERTSON, PEGGY ANN (LMSW, ACSW)
Entity type:Individual
Prefix:MRS
First Name:PEGGY
Middle Name:ANN
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:LMSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23933 ALLEN RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WOODHAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:48183-3372
Mailing Address - Country:US
Mailing Address - Phone:734-692-6440
Mailing Address - Fax:734-692-7708
Practice Address - Street 1:23933 ALLEN RD
Practice Address - Street 2:SUITE 3
Practice Address - City:WOODHAVEN
Practice Address - State:MI
Practice Address - Zip Code:48183-3372
Practice Address - Country:US
Practice Address - Phone:734-692-6440
Practice Address - Fax:734-692-7708
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010601451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM60350Medicare ID - Type Unspecified