Healthcare Provider Details

I. General information

NPI: 1396770434
Provider Name (Legal Business Name): BRUCE J. ROBERTSON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 09/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2631 PACKERLAND DR SUITE 104-C
GREEN BAY WI
54313-4130
US

IV. Provider business mailing address

2631 PACKERLAND DR SUITE 104-C
GREEN BAY WI
54313-4130
US

V. Phone/Fax

Practice location:
  • Phone: 920-965-7701
  • Fax: 920-497-4956
Mailing address:
  • Phone: 920-965-7701
  • Fax: 920-497-4956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1992-057
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: