Provider Demographics
NPI:1073917720
Name:ROBERTS, REGINALD (PHD)
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 ALBERTA DR
Mailing Address - Street 2:SUITE 211
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-1814
Mailing Address - Country:US
Mailing Address - Phone:716-837-6705
Mailing Address - Fax:716-837-6759
Practice Address - Street 1:315 ALBERTA DR
Practice Address - Street 2:SUITE 211
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-1814
Practice Address - Country:US
Practice Address - Phone:716-837-6705
Practice Address - Fax:716-837-6759
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015549103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist