Provider Demographics
NPI:1275640849
Name:ROBERTSON, PETER D (LCSW)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:D
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 96
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:ME
Mailing Address - Zip Code:04040-0096
Mailing Address - Country:US
Mailing Address - Phone:207-647-2037
Mailing Address - Fax:207-647-2037
Practice Address - Street 1:226A PORTLAND ROAD
Practice Address - Street 2:RTE 302
Practice Address - City:BRIDGTON
Practice Address - State:ME
Practice Address - Zip Code:04005-0000
Practice Address - Country:US
Practice Address - Phone:207-647-2037
Practice Address - Fax:207-647-2037
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC30861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical