Healthcare Provider Details

I. General information

NPI: 1730413626
Provider Name (Legal Business Name): LISA GARETY ROBERTS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2009
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 GRESHAM DR FL 9
NORFOLK VA
23507
US

IV. Provider business mailing address

401 GRESHAM DR FL 9
NORFOLK VA
23507
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-7054
  • Fax: 757-953-6081
Mailing address:
  • Phone: 757-668-7054
  • Fax: 757-953-6081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0810004479
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number0810004479
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810004479
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: