Healthcare Provider Details

I. General information

NPI: 1417158288
Provider Name (Legal Business Name): ROBYN KERVICK PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 COLLEGE PKWY
COLCHESTER VT
05446-3007
US

IV. Provider business mailing address

160 COMMONWEALTH AVENUE SUITE U3
BOSTON MA
02116
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-3634
  • Fax:
Mailing address:
  • Phone: 617-259-1895
  • Fax: 617-259-1899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number048-0134257
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number8520
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: