Provider Demographics
NPI:1639193683
Name:ROBERTS, BRUCE E (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:E
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:859 WILLARD ST
Mailing Address - Street 2:STE 430
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-7482
Mailing Address - Country:US
Mailing Address - Phone:617-847-1950
Mailing Address - Fax:617-774-1490
Practice Address - Street 1:859 WILLARD ST
Practice Address - Street 2:STE 430
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-7482
Practice Address - Country:US
Practice Address - Phone:617-847-1950
Practice Address - Fax:617-774-1490
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7604103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW05986OtherBLUE CROSS BLUE SHIELD
MAW50516Medicare ID - Type Unspecified