Provider Demographics
NPI:1225113400
Name:ROBERTSON, GARY L (HIS)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:L
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:KENOVA
Mailing Address - State:WV
Mailing Address - Zip Code:25530-1235
Mailing Address - Country:US
Mailing Address - Phone:304-453-3171
Mailing Address - Fax:304-453-4793
Practice Address - Street 1:1431 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:KENOVA
Practice Address - State:WV
Practice Address - Zip Code:25530-1235
Practice Address - Country:US
Practice Address - Phone:304-453-3171
Practice Address - Fax:304-453-4793
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV873237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist