Provider Demographics
NPI:1679826374
Name:ROBERTSON, REGINALD SHAWN (LCDCI)
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:SHAWN
Last Name:ROBERTSON
Suffix:
Gender:
Credentials:LCDCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 POST OAK DR
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75089-7128
Mailing Address - Country:US
Mailing Address - Phone:469-364-1082
Mailing Address - Fax:
Practice Address - Street 1:4500 S LANCASTER RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-7167
Practice Address - Country:US
Practice Address - Phone:214-927-4617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-18
Last Update Date:2025-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1375101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)