Provider Demographics
NPI:1649200700
Name:ROBERTSON, EDWIN D (PHD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:D
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:PO BOX 9477
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-9477
Mailing Address - Country:US
Mailing Address - Phone:903-594-2450
Mailing Address - Fax:903-509-0493
Practice Address - Street 1:701 OLYMPIC PLAZA CIR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1950
Practice Address - Country:US
Practice Address - Phone:903-596-3000
Practice Address - Fax:903-596-3006
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24420103T00000X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
8C9943Medicare ID - Type Unspecified