Provider Demographics
NPI:1639315617
Name:ROBERSON, CHARLES RICHARD JR
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:RICHARD
Last Name:ROBERSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E. WALNUT ST. 200
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101
Mailing Address - Country:US
Mailing Address - Phone:626-356-5311
Mailing Address - Fax:626-568-1914
Practice Address - Street 1:300 E WALNUT ST # 200
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-1584
Practice Address - Country:US
Practice Address - Phone:626-356-5311
Practice Address - Fax:626-568-1914
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-23
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YP2500X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst