Provider Demographics
NPI:1730289364
Name:ROBERTS, MARY R (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:R
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 CYPRESS CT
Mailing Address - Street 2:
Mailing Address - City:LITTLE EGG HARBOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08087-4231
Mailing Address - Country:US
Mailing Address - Phone:609-296-3289
Mailing Address - Fax:609-296-0022
Practice Address - Street 1:126 N GREEN ST
Practice Address - Street 2:
Practice Address - City:TUCKERTON
Practice Address - State:NJ
Practice Address - Zip Code:08087-2628
Practice Address - Country:US
Practice Address - Phone:609-296-0022
Practice Address - Fax:609-296-0022
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00286000103T00000X
PAPS002617L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ038178OtherMHN
NJ2551979OtherAETNA