Provider Demographics
NPI:1366271751
Name:ROBERSON, DESTINY
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 E BREWTON ST
Mailing Address - Street 2:
Mailing Address - City:MC RAE HELENA
Mailing Address - State:GA
Mailing Address - Zip Code:31055-3201
Mailing Address - Country:US
Mailing Address - Phone:229-212-9400
Mailing Address - Fax:
Practice Address - Street 1:1717 RICE AVE
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-3524
Practice Address - Country:US
Practice Address - Phone:478-279-7214
Practice Address - Fax:833-478-1298
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-22-250233106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician