Provider Demographics
NPI:1518406248
Name:ROBERTSON, CHARISSA MARIE (CADC-III)
Entity type:Individual
Prefix:
First Name:CHARISSA
Middle Name:MARIE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:CADC-III
Other - Prefix:
Other - First Name:CHERRY
Other - Middle Name:
Other - Last Name:ROBERTSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CADC- II
Mailing Address - Street 1:45435 SAND CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SQUAW VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93675-9328
Mailing Address - Country:US
Mailing Address - Phone:559-341-3657
Mailing Address - Fax:
Practice Address - Street 1:3707 E SHIELDS AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-7029
Practice Address - Country:US
Practice Address - Phone:559-229-9040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-14
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB00003570824101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA770534019Medicaid