=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154469617
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NANCY ELLEN ROBERTS PSY.D., PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5 SCHOOL ST
-----------------------------------------------------
City | ELLSWORTH
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04605-1932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-852-7656
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 693
-----------------------------------------------------
City | HOLDEN
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04429-0693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-852-7656
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PS882
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------