Provider Demographics
NPI:1326166935
Name:ROBERTSON, GAYLE MARIE (MA)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:MARIE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 W VALLEY WAY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65810-2578
Mailing Address - Country:US
Mailing Address - Phone:417-877-0913
Mailing Address - Fax:
Practice Address - Street 1:380 E. HWY CC
Practice Address - Street 2:SUITE A105
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714
Practice Address - Country:US
Practice Address - Phone:417-725-8810
Practice Address - Fax:417-725-6206
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001011927101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional