Provider Demographics
NPI:1275515033
Name:ROBERTSON, PHYLLIS M (BCD)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:M
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18TH MEDICAL GROUP
Mailing Address - Street 2:UNIT 5142
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96368
Mailing Address - Country:US
Mailing Address - Phone:080-634-8523
Mailing Address - Fax:
Practice Address - Street 1:18 MEDICAL GROUP
Practice Address - Street 2:UNIT 5142
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96368
Practice Address - Country:US
Practice Address - Phone:01180-634-8523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-35281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical