Healthcare Provider Details

I. General information

NPI: 1285453894
Provider Name (Legal Business Name): PAUL LAMAR ROBERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2024
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2594 INDUSTRY WAY
LYNWOOD CA
90262-4015
US

IV. Provider business mailing address

3850 CRENSHAW BLVD
LOS ANGELES CA
90008-1821
US

V. Phone/Fax

Practice location:
  • Phone: 310-667-4070
  • Fax:
Mailing address:
  • Phone: 323-593-5300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number128926
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: