Provider Demographics
NPI:1619963394
Name:ROBERTS, FREDRIC BURTON (ED D)
Entity Type:Individual
Prefix:DR
First Name:FREDRIC
Middle Name:BURTON
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:ED D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 HURON AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3763
Mailing Address - Country:US
Mailing Address - Phone:810-984-4550
Mailing Address - Fax:810-987-3737
Practice Address - Street 1:1025 HURON AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3763
Practice Address - Country:US
Practice Address - Phone:810-984-4550
Practice Address - Fax:810-987-3737
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002615103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
680G445000OtherBCBS
0N35510Medicare ID - Type Unspecified
R75753Medicare UPIN