Healthcare Provider Details

I. General information

NPI: 1558346395
Provider Name (Legal Business Name): MARVIN A. MCROBERTS PSYCHOTHERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 DAVENPORT MOUNTAIN RD
BLUE RIDGE GA
30513-5616
US

IV. Provider business mailing address

605 DAVENPORT MOUNTAIN RD
BLUE RIDGE GA
30513-5616
US

V. Phone/Fax

Practice location:
  • Phone: 706-258-6226
  • Fax: 708-258-6226
Mailing address:
  • Phone: 706-258-6226
  • Fax: 708-258-6226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC004080
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: