1659902393 NPI number — MR. OTIS LAMONTE ROBERSON II LCSW-A

Table of content: MR. OTIS LAMONTE ROBERSON II LCSW-A (NPI 1659902393)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659902393 NPI number — MR. OTIS LAMONTE ROBERSON II LCSW-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERSON
Provider First Name:
OTIS
Provider Middle Name:
LAMONTE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
II
Provider Credential Text:
LCSW-A
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROBERSON
Provider Other First Name:
OTIS
Provider Other Middle Name:
LAMONTE
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
II
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659902393
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2008 S MEBANE ST APT E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27215-7614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-352-1939
Provider Business Mailing Address Fax Number:
844-272-1223

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2008 S MEBANE ST APT E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27215-7614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-352-1939
Provider Business Practice Location Address Fax Number:
844-272-1223
Provider Enumeration Date:
01/31/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  P014268 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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