MEDICARE: DR. ROBERT SPERRY JR. PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TS0200X	School Psychologist	6166	TX
2	103TC0700X	Clinical Psychologist	23178	TX
3	103G00000X	Clinical Neuropsychologist	23178	TX
4	103TC2200X	Clinical Child & Adolescent Psychologist	23178	TX
5	103TF0200X	Forensic Psychologist	23178	TX
6	103TM1800X	Intellectual & Developmental Disabilities Psychologist	23178	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0082EF	OTHER	TX	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497805659
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT SPERRY JR. PH.D.

Provider Business Mailing Address
First Line	:	PO BOX 2186
Second Line	:
City	:	FLINT
State	:	TX
Zip	:	75762-2186
Country	:	US
Telephone Number	:	903-534-5968
Fax Number	:

Provider Business Practice Location Address
First Line	:	3334 SSW LOOP 323
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75701-9237
Country	:	US
Telephone Number	:	903-534-5968
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	05/25/2021

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Directions to “ DR. ROBERT SPERRY JR. PH.D.” Practice Location

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