Provider Demographics
NPI:1114594207
Name:ROBERSON, ALYSSA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ALYSSA
Middle Name:
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 CANAL ST STE D
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-6019
Mailing Address - Country:US
Mailing Address - Phone:478-697-1458
Mailing Address - Fax:
Practice Address - Street 1:131 CANAL ST STE D
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-6019
Practice Address - Country:US
Practice Address - Phone:912-988-3181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-07
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004453103T00000X, 103TH0100X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service