MEDICARE: DEREK ROBERTSON L.M.S.W.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6801086213	MI

General Provider Information

NPI Number	:	1720441983
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK ROBERTSON L.M.S.W.

Provider Business Mailing Address
First Line	:	715 HUNT ST
Second Line	:
City	:	LOWELL
State	:	MI
Zip	:	49331-1033
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	441 SWARTZ COURT
Second Line	:
City	:	IONIA
State	:	MI
Zip	:	48846-1639
Country	:	US
Telephone Number	:	616-523-6537
Fax Number	:	616-523-6536

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/04/2016
Last Update Date	:	02/01/2017

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