Provider Demographics
NPI:1992775704
Name:ROBERSON, MARY KATHLEEN (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:KATHLEEN
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6408
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37831-3733
Mailing Address - Country:US
Mailing Address - Phone:865-482-0981
Mailing Address - Fax:865-482-0959
Practice Address - Street 1:665 EMORY VALLEY RD
Practice Address - Street 2:STE. A
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-7762
Practice Address - Country:US
Practice Address - Phone:865-482-0981
Practice Address - Fax:865-482-0959
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP-1349103TA0400X, 103TA0700X, 103TC0700X, 103TB0200X, 103TC2200X, 103TF0000X, 103TC1900X, 103TH0100X
TN4367660225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Not Answered103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3687063Medicaid
TN3687063Medicare ID - Type Unspecified
TN3687063Medicaid