Healthcare Provider Details

I. General information

NPI: 1346537032
Provider Name (Legal Business Name): MARY LYNN ROBERTS M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2011
Last Update Date: 04/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 CAROLINA ST #114
GREENSBORO NC
27401-1032
US

IV. Provider business mailing address

1301 CAROLINA ST #114
GREENSBORO NC
27401-1032
US

V. Phone/Fax

Practice location:
  • Phone: 920-219-2307
  • Fax:
Mailing address:
  • Phone: 920-219-2307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-21688
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA12103
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: