Healthcare Provider Details

I. General information

NPI: 1003496159
Provider Name (Legal Business Name): COLLEEN M ROBERTS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1727 N OCEAN AVE
MEDFORD NY
11763-2649
US

IV. Provider business mailing address

1727 N OCEAN AVE
MEDFORD NY
11763-2649
US

V. Phone/Fax

Practice location:
  • Phone: 631-654-1919
  • Fax:
Mailing address:
  • Phone: 631-654-1919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number117163-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: