=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306274154
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LESLIE WALKER ROBERSON PSY.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2013
-----------------------------------------------------
Last Update Date | 12/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 590 MEDICAL CENTER ROAD BUILDING 36065 FORT CAVAZOS
-----------------------------------------------------
City | FT CAVAZOS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-618-8420
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 E HOSPITAL RD
-----------------------------------------------------
City | FORT GORDON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30905-5741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 08100005170
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------