Healthcare Provider Details

I. General information

NPI: 1831059187
Provider Name (Legal Business Name): MARISEL GAVIRIA ROBERTSON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2025
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 HOLLY HILLS AVE
SAINT LOUIS MO
63111-2410
US

IV. Provider business mailing address

3004 TEXAS AVE
SAINT LOUIS MO
63118-1530
US

V. Phone/Fax

Practice location:
  • Phone: 314-353-5190
  • Fax: 314-353-7631
Mailing address:
  • Phone: 310-221-1160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2023041227
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: