=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568672350
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE KATALIN ROBERTSON LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2007
-----------------------------------------------------
Last Update Date | 03/23/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 EASTBROOK RD STE 302 RIVERSIDE COMMUNITY CARE
-----------------------------------------------------
City | DEDHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02026-2084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-329-4579
-----------------------------------------------------
Fax | 781-329-8631
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 EASTBROOK RD STE 302 RIVERSIDE COMMUNITY CARE
-----------------------------------------------------
City | DEDHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02026-2084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-329-4579
-----------------------------------------------------
Fax | 781-329-8631
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 120033
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------