MEDICARE: DR. TERRI LEE ROBERSON

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	103TC0700X	Clinical Psychologist	21565	CA

General Provider Information

NPI Number	:	1972079143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERRI LEE ROBERSON

Provider Business Mailing Address
First Line	:	19337 APPLE VALLEY RD
Second Line	:
City	:	SONOMA
State	:	CA
Zip	:	95476-4824
Country	:	US
Telephone Number	:	707-771-0337
Fax Number	:

Provider Business Practice Location Address
First Line	:	19337 APPLE VALLEY RD
Second Line	:
City	:	SONOMA
State	:	CA
Zip	:	95476-4824
Country	:	US
Telephone Number	:	707-771-0337
Fax Number	:

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

Provider Enumeration Date	:	10/15/2018
Last Update Date	:	10/15/2018

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