Healthcare Provider Details

I. General information

NPI: 1447579487
Provider Name (Legal Business Name): ROBERTS MEDICAL PSYCHOLOGY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2010
Last Update Date: 09/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2929 COORS BLVD NW 201H
ALBUQUERQUE NM
87120-1173
US

IV. Provider business mailing address

1534 REEVES ST
LOS ANGELES CA
90035-2929
US

V. Phone/Fax

Practice location:
  • Phone: 505-312-7070
  • Fax: 310-553-5288
Mailing address:
  • Phone: 310-552-2382
  • Fax: 310-553-5288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY13524
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1255
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number0043
License Number StateNM

VIII. Authorized Official

Name: ALLAN RAY ROBERTS
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 505-312-7070