Provider Demographics
NPI:1326505926
Name:ROBERTSON, SCOTT JR (CG60940327)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:
Last Name:ROBERTSON
Suffix:JR
Gender:M
Credentials:CG60940327
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 JALYN ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-1730
Mailing Address - Country:US
Mailing Address - Phone:360-807-3597
Mailing Address - Fax:
Practice Address - Street 1:151 N MARKET BLVD STE D
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-2677
Practice Address - Country:US
Practice Address - Phone:360-948-0288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-01
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG60940327OtherCOUNSELOR AGENCY AFFILIATED REGISTRATION