Provider Demographics
NPI:1578714804
Name:FREDRIC B ROBERTS EDD PC
Entity Type:Organization
Organization Name:FREDRIC B ROBERTS EDD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDRIC
Authorized Official - Middle Name:B
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:810-984-4550
Mailing Address - Street 1:2033 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3207
Mailing Address - Country:US
Mailing Address - Phone:810-984-4550
Mailing Address - Fax:810-984-3737
Practice Address - Street 1:2033 11TH AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3207
Practice Address - Country:US
Practice Address - Phone:810-984-4550
Practice Address - Fax:810-984-3737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty