Provider Demographics
NPI:1992229173
Name:ROBERTSON, MARCY BOOKER
Entity type:Individual
Prefix:
First Name:MARCY
Middle Name:BOOKER
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 1:402 E CRAIG ST
Mailing Address - Street 2:
Mailing Address - City:TALLULAH
Mailing Address - State:LA
Mailing Address - Zip Code:71282-3718
Mailing Address - Country:US
Mailing Address - Phone:318-574-9009
Mailing Address - Fax:
Practice Address - Street 1:402 E CRAIG ST
Practice Address - Street 2:
Practice Address - City:TALLULAH
Practice Address - State:LA
Practice Address - Zip Code:71282-3718
Practice Address - Country:US
Practice Address - Phone:318-574-9009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-31
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA770641488385H00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health