Healthcare Provider Details

I. General information

NPI: 1235362914
Provider Name (Legal Business Name): GARY A ROBERSON PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2009
Last Update Date: 08/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

797 WOODLAND DR
STUART VA
24171-5132
US

IV. Provider business mailing address

4209 LAKELAND DR STE 240
FLOWOOD MS
39232-9212
US

V. Phone/Fax

Practice location:
  • Phone: 601-201-5009
  • Fax: 601-487-8420
Mailing address:
  • Phone: 601-951-9863
  • Fax: 601-487-8897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DR. GARY ALAN ROBERSON
Title or Position: MEMBER
Credential: M.D.
Phone: 601-201-5009