Healthcare Provider Details

I. General information

NPI: 1780185074
Provider Name (Legal Business Name): RENE ROBERTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2018
Last Update Date: 02/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42000 6 MILE RD STE 202
NORTHVILLE MI
48168-4374
US

IV. Provider business mailing address

42000 6 MILE RD STE 202
NORTHVILLE MI
48168-4374
US

V. Phone/Fax

Practice location:
  • Phone: 248-283-3703
  • Fax:
Mailing address:
  • Phone: 248-283-3703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301015920
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301015920
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: