Provider Demographics
NPI:1417158288
Name:KERVICK, ROBYN (PHD)
Entity Type:Individual
Prefix:
First Name:ROBYN
Middle Name:
Last Name:KERVICK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 COMMONWEALTH AVENUE
Mailing Address - Street 2:SUITE U3
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116
Mailing Address - Country:US
Mailing Address - Phone:617-259-1895
Mailing Address - Fax:617-259-1899
Practice Address - Street 1:790 COLLEGE PKWY
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-3007
Practice Address - Country:US
Practice Address - Phone:802-847-3634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8520103G00000X
VT048-01342572084N0600X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW06450OtherBLUE CROSS PROVIDER #
MAW06450OtherBLUE CROSS PROVIDER #