Provider Demographics
NPI:1114465242
Name:ROBERTS, MICHAEL BRUCE (PSYD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRUCE
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 HADDON AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1505
Mailing Address - Country:US
Mailing Address - Phone:856-757-7719
Mailing Address - Fax:
Practice Address - Street 1:401 HADDON AVE FL 3
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-1505
Practice Address - Country:US
Practice Address - Phone:856-757-7719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00573200103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist