Provider Demographics
NPI:1487852935
Name:MAILLIARD, ROBERT L (PSYCHOLOGIST)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:MAILLIARD
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 E 2ND ST
Mailing Address - Street 2:THIRD FLOOR
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1537
Mailing Address - Country:US
Mailing Address - Phone:814-877-8013
Mailing Address - Fax:814-877-8007
Practice Address - Street 1:120 E 2ND ST
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1537
Practice Address - Country:US
Practice Address - Phone:814-877-8013
Practice Address - Fax:814-877-8007
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS016253103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1019567000Medicaid