MEDICARE: DR. BRUCE J. ROBERTSON PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	1992-057	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396770434
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRUCE J. ROBERTSON PHD

Provider Business Mailing Address
First Line	:	2631 PACKERLAND DR
Second Line	:	SUITE 104-C
City	:	GREEN BAY
State	:	WI
Zip	:	54313-4130
Country	:	US
Telephone Number	:	920-965-7701
Fax Number	:	920-497-4956

Provider Business Practice Location Address
First Line	:	2631 PACKERLAND DR
Second Line	:	SUITE 104-C
City	:	GREEN BAY
State	:	WI
Zip	:	54313-4130
Country	:	US
Telephone Number	:	920-965-7701
Fax Number	:	920-497-4956

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	09/12/2009

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