Healthcare Provider Details

I. General information

NPI: 1346342276
Provider Name (Legal Business Name): GLENROY JEROME ROBINSON LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 HERITAGE WAY NE SUITE 302
LEESBURG VA
20176-4544
US

IV. Provider business mailing address

109 CALEDONIA DR
MARTINSBURG WV
25401-5196
US

V. Phone/Fax

Practice location:
  • Phone: 703-771-5100
  • Fax: 703-777-0170
Mailing address:
  • Phone: 304-262-1572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701003824
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: