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General NPI Number Information
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NPI Number | 1114556164
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Entity Type | Individual
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Provider Name | MARISSA AKIKO ROBERTSON
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Gender | Female
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Dates
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Enumeration Date | 04/02/2020
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Last Update Date | 06/13/2020
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Provider Practice Location Address
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Address Line | 5841 S MARYLAND AVE # MC1052
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City | CHICAGO
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State | IL
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Zip | 60637-1443
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Country | US
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Telephone | 212-263-5506
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Fax |
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Provider Business Mailing Address
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Address Line | 180 HARVESTER DR STE 110
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City | BURR RIDGE
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State | IL
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Zip | 60527-6686
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Country | US
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Telephone | 773-702-1150
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Fax |
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 125.075988
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License Number State | IL
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