Provider Demographics
NPI:1881230134
Name:ROBERTSON, GREGORY JOHN (LADC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:JOHN
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6969 VALLEY CREEK ROAD
Mailing Address - Street 2:220
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125
Mailing Address - Country:US
Mailing Address - Phone:651-210-5287
Mailing Address - Fax:651-212-4884
Practice Address - Street 1:1380 ENERGY LN STE 203
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-5253
Practice Address - Country:US
Practice Address - Phone:651-210-5287
Practice Address - Fax:651-212-4884
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300291101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN13465318094Medicaid