Healthcare Provider Details

I. General information

NPI: 1114703162
Provider Name (Legal Business Name): ROBERT PEMBERTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2023
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 3RD AVE
CHESAPEAKE OH
45619-1036
US

IV. Provider business mailing address

3609 CRANE AVE
HUNTINGTON WV
25705-1721
US

V. Phone/Fax

Practice location:
  • Phone: 740-451-1455
  • Fax:
Mailing address:
  • Phone: 304-690-0582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.186235
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: