Healthcare Provider Details

I. General information

NPI: 1073876421
Provider Name (Legal Business Name): MISS CAMBREA ROBERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2012
Last Update Date: 06/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W I 44 SERVICE RD STE 103
OKLAHOMA CITY OK
73112-8739
US

IV. Provider business mailing address

2000 WOODLAWN AVE APT C4
GUTHRIE OK
73044-5765
US

V. Phone/Fax

Practice location:
  • Phone: 405-557-1655
  • Fax:
Mailing address:
  • Phone: 405-924-5576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberR083090929
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: