Provider Demographics
NPI:1609070069
Name:ROBERTSON, KENNETH DILLON (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:DILLON
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3604 FORT PEYTON CIR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-9101
Mailing Address - Country:US
Mailing Address - Phone:904-540-5310
Mailing Address - Fax:
Practice Address - Street 1:3604 FORT PEYTON CIR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-9101
Practice Address - Country:US
Practice Address - Phone:904-540-5310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 6760103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist