Provider Demographics
NPI:1497959811
Name:ROBERTSON, DILICE G (APRN,PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:DILICE
Middle Name:G
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:APRN,PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 OXFORD RD UNIT L
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06478-1900
Mailing Address - Country:US
Mailing Address - Phone:203-463-4555
Mailing Address - Fax:203-517-0058
Practice Address - Street 1:71 OXFORD RD UNIT L
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:CT
Practice Address - Zip Code:06478-1900
Practice Address - Country:US
Practice Address - Phone:203-463-4555
Practice Address - Fax:203-517-0058
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT81733163W00000X, 163WA0400X, 163WP0809X, 163WP0807X
CT2008008396364SP0810X
CT003973363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No364SP0810XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Family
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235900Medicaid
D400024182Medicare UPIN