Healthcare Provider Details

I. General information

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

II. Dates (important events)

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

III. Provider practice location address

3525 RESOURCE DRIVE ROOM C-44
RANDALLSTOWN MD
21133
US

IV. Provider business mailing address

10400 RIDGLAND ROAD STE 1
COCKEYSVILLE MD
21030
US

V. Phone/Fax

Practice location:
  • Phone: 410-655-7655
  • Fax: 410-655-3941
Mailing address:
  • Phone: 410-628-6120
  • Fax: 410-628-9825

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: