Healthcare Provider Details

I. General information

NPI: 1598263980
Provider Name (Legal Business Name): SUSAN ROBERTSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2018
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1191 CENTRAL BLVD STE A
BRENTWOOD CA
94513-2253
US

IV. Provider business mailing address

PO BOX 740780
ATLANTA GA
30374-0780
US

V. Phone/Fax

Practice location:
  • Phone: 855-223-7123
  • Fax: 619-374-7134
Mailing address:
  • Phone: 855-223-7123
  • Fax: 619-374-7134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-61648
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number00002419
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: