Provider Demographics
NPI:1982439949
Name:ROBERTSON, TENNIS
Entity type:Individual
Prefix:
First Name:TENNIS
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 1:5901 BRANDON DUNES DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40228-1157
Mailing Address - Country:US
Mailing Address - Phone:412-606-7368
Mailing Address - Fax:
Practice Address - Street 1:5901 BRANDON DUNES DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40228-1157
Practice Address - Country:US
Practice Address - Phone:412-606-7368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-07
Last Update Date:2024-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY294367101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty