Provider Demographics
NPI:1366263071
Name:ROBERTSON, BROOKLYN NICOLE (LCSW, LAC)
Entity type:Individual
Prefix:MRS
First Name:BROOKLYN
Middle Name:NICOLE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:LCSW, LAC
Other - Prefix:MISS
Other - First Name:BROOKLYN
Other - Middle Name:NICOLE
Other - Last Name:AMBUEHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:550 N CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-3913
Mailing Address - Country:US
Mailing Address - Phone:406-541-1671
Mailing Address - Fax:406-721-0034
Practice Address - Street 1:550 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-3913
Practice Address - Country:US
Practice Address - Phone:406-868-4861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-LIC-70324101YA0400X
MTBBH-LCSW-LIC-729211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)