Provider Demographics
NPI:1508353236
Name:ROBERTSON, REBECCA JEAN (PCA)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:JEAN
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:PCA
Other - Prefix:MS
Other - First Name:REBECCA
Other - Middle Name:JEAN
Other - Last Name:KAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:184 BLACKLOG ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT GAY
Mailing Address - State:WV
Mailing Address - Zip Code:25514
Mailing Address - Country:US
Mailing Address - Phone:304-272-6671
Mailing Address - Fax:304-272-6671
Practice Address - Street 1:184 BLACKLOG ROAD
Practice Address - Street 2:
Practice Address - City:FORT GAY
Practice Address - State:WV
Practice Address - Zip Code:25514
Practice Address - Country:US
Practice Address - Phone:304-272-6671
Practice Address - Fax:304-272-6671
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant