Provider Demographics
NPI:1558504191
Name:ROBERSON, GWENDOLYN EARLE (MD, MA)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:EARLE
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:MD, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 S 1100 E
Mailing Address - Street 2:404
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1686
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1120 ROUTE 73 STE 300
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-5113
Practice Address - Country:US
Practice Address - Phone:856-930-4097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-13
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7770041-1205103T00000X, 2084P0800X
MN706642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1558504191Medicaid