Healthcare Provider Details

I. General information

NPI: 1518406248
Provider Name (Legal Business Name): CHARISSA MARIE ROBERTSON CADC-III
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHERRY ROBERTSON CADC- II

II. Dates (important events)

Enumeration Date: 02/14/2017
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3707 E SHIELDS AVE
FRESNO CA
93726-7029
US

IV. Provider business mailing address

45435 SAND CREEK RD
SQUAW VALLEY CA
93675-9328
US

V. Phone/Fax

Practice location:
  • Phone: 559-229-9040
  • Fax:
Mailing address:
  • Phone: 559-341-3657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number21432
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: