Provider Demographics
NPI:1508023540
Name:ROBERTSON, GRETTA CHRISTINE (MS-CCC-SLP)
Entity Type:Individual
Prefix:
First Name:GRETTA
Middle Name:CHRISTINE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:MS-CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 PHILLIPSITE LN
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-6178
Mailing Address - Country:US
Mailing Address - Phone:770-292-9846
Mailing Address - Fax:
Practice Address - Street 1:4010 PHILLIPSITE LN
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-6178
Practice Address - Country:US
Practice Address - Phone:770-292-9846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006649235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA738798939AMedicaid