Healthcare Provider Details

I. General information

NPI: 1609070069
Provider Name (Legal Business Name): KENNETH DILLON ROBERTSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3604 FORT PEYTON CIR
ST AUGUSTINE FL
32086-9101
US

IV. Provider business mailing address

3604 FORT PEYTON CIR
ST AUGUSTINE FL
32086-9101
US

V. Phone/Fax

Practice location:
  • Phone: 904-540-5310
  • Fax:
Mailing address:
  • Phone: 904-540-5310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY 6760
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: