Provider Demographics
NPI:1114703162
Name:PEMBERTON, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:PEMBERTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3609 CRANE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-1721
Mailing Address - Country:US
Mailing Address - Phone:304-690-0582
Mailing Address - Fax:
Practice Address - Street 1:517 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:OH
Practice Address - Zip Code:45619-1036
Practice Address - Country:US
Practice Address - Phone:740-451-1455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-06
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
WVCDCA.186235101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)