Healthcare Provider Details

I. General information

NPI: 1871325753
Provider Name (Legal Business Name): HAILY SOPHIA ROBERTSON LCMHCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 RIDGE AVE
CHERRYVILLE NC
28021-2451
US

IV. Provider business mailing address

200 E 2ND AVE
GASTONIA NC
28052-4358
US

V. Phone/Fax

Practice location:
  • Phone: 704-836-9605
  • Fax:
Mailing address:
  • Phone: 704-874-1907
  • Fax: 704-865-4614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA20456
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: