Provider Demographics
NPI:1396185096
Name:NORTHCUTT, ROBERT GLEN (MA)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:GLEN
Last Name:NORTHCUTT
Suffix:
Gender:M
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:PO BOX 502631
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92150-2631
Mailing Address - Country:US
Mailing Address - Phone:858-829-7029
Mailing Address - Fax:866-384-6394
Practice Address - Street 1:8632 S SEPULVEDA BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-4015
Practice Address - Country:US
Practice Address - Phone:310-606-2026
Practice Address - Fax:866-384-6394
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51430106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist