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General NPI Number Information
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NPI Number | 1114066321
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Entity Type | Individual
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Provider Name | DEREK LANE ROBERTSON M. ED., LPC
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Gender | Male
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Dates
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Enumeration Date | 02/05/2007
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Last Update Date | 10/13/2009
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Provider Practice Location Address
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Address Line | 516 COLLEGE AVE
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City | FORT WORTH
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State | TX
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Zip | 76104-2238
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Country | US
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Telephone | 806-543-6585
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Fax | 817-231-0132
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Provider Business Mailing Address
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Address Line | 2420 S ADAMS ST
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City | FORT WORTH
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State | TX
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Zip | 76110-2609
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Country | US
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Telephone | 806-543-6585
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Fax | 817-231-0132
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 14021
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License Number State | TX
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