Provider Demographics
NPI:1679112320
Name:EGBERT, ROBERT DALE (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DALE
Last Name:EGBERT
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 1:1120 SE COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:99324-1804
Mailing Address - Country:US
Mailing Address - Phone:509-540-4377
Mailing Address - Fax:
Practice Address - Street 1:1120 SE COLONIAL DR
Practice Address - Street 2:
Practice Address - City:COLLEGE PLACE
Practice Address - State:WA
Practice Address - Zip Code:99324-1804
Practice Address - Country:US
Practice Address - Phone:509-540-4377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-29
Last Update Date:2019-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00004684101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALH00004684OtherSTATE OF WASHINGTON