Provider Demographics
NPI:1699807164
Name:ROBERSON, VIRGIL EVERETT (LP, MDIV,MA)
Entity Type:Individual
Prefix:MR
First Name:VIRGIL
Middle Name:EVERETT
Last Name:ROBERSON
Suffix:
Gender:M
Credentials:LP, MDIV,MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 BROADWAY
Mailing Address - Street 2:SUITE #600
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-6008
Mailing Address - Country:US
Mailing Address - Phone:212-581-5428
Mailing Address - Fax:
Practice Address - Street 1:928 BROADWAY
Practice Address - Street 2:SUITE #600
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-6008
Practice Address - Country:US
Practice Address - Phone:212-581-5428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000040-1102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst