Healthcare Provider Details

I. General information

NPI: 1538355037
Provider Name (Legal Business Name): BERNARD ROBERSON LCA 138
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2007
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 POPLAR DR
BALTIMORE MD
21207-6088
US

IV. Provider business mailing address

2710 POPLAR DR
BALTIMORE MD
21207-6088
US

V. Phone/Fax

Practice location:
  • Phone: 443-794-3439
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCA138
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: