Provider Demographics
NPI:1043016462
Name:ROBERSON, TERESA R
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:R
Last Name:ROBERSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5720 S 77TH ST
Mailing Address - Street 2:
Mailing Address - City:RALSTON
Mailing Address - State:NE
Mailing Address - Zip Code:68127-4202
Mailing Address - Country:US
Mailing Address - Phone:531-200-0563
Mailing Address - Fax:
Practice Address - Street 1:5720 S 77TH ST
Practice Address - Street 2:
Practice Address - City:RALSTON
Practice Address - State:NE
Practice Address - Zip Code:68127-4202
Practice Address - Country:US
Practice Address - Phone:531-200-0563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities