Provider Demographics
NPI:1902296502
Name:ROBERSON, MARY (LCPC, EDD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:LCPC, EDD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:COLLINS HENDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC, EDD
Mailing Address - Street 1:39385 N STOCKTON LN
Mailing Address - Street 2:
Mailing Address - City:BEACH PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60083-3010
Mailing Address - Country:US
Mailing Address - Phone:847-687-3504
Mailing Address - Fax:
Practice Address - Street 1:39385 N STOCKTON LN
Practice Address - Street 2:
Practice Address - City:BEACH PARK
Practice Address - State:IL
Practice Address - Zip Code:60083-3010
Practice Address - Country:US
Practice Address - Phone:847-687-3504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-03
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180005805101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional