Healthcare Provider Details

I. General information

NPI: 1225194343
Provider Name (Legal Business Name): MARK ROBERTS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 E 73RD ST
NEW YORK NY
10021-3865
US

IV. Provider business mailing address

2600 NETHERLAND AVE APT 2401
BRONX NY
10463-4839
US

V. Phone/Fax

Practice location:
  • Phone: 212-787-3128
  • Fax:
Mailing address:
  • Phone: 718-884-1488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number000556
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: