Provider Demographics
NPI:1639328628
Name:ROBERTSON, DAVID KERR
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:KERR
Last Name:ROBERTSON
Suffix:
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 1:39 PRIESTLY PL
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-9323
Mailing Address - Country:US
Mailing Address - Phone:505-899-6278
Mailing Address - Fax:
Practice Address - Street 1:39 PRIESTLY PL
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-9323
Practice Address - Country:US
Practice Address - Phone:505-899-6278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-15
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0089111101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)