Provider Demographics
NPI:1972076818
Name:ROBERTSON, PHYLLIS MARY (BA, MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:MARY
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:BA, MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 POPLAR AVE.
Mailing Address - Street 2:
Mailing Address - City:SAULT STE. MARIE
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:P6B 2W6
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:37 POPLAR AVE.
Practice Address - Street 2:
Practice Address - City:SAULT STE. MARIE
Practice Address - State:ONTARIO
Practice Address - Zip Code:P6B 2W6
Practice Address - Country:CA
Practice Address - Phone:705-255-2868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-03
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101003599235Z00000X
IN22007955A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN22007955AOtherINDIANA PROFESSIONAL LICENSING AGENCY
MI7101003599OtherBOARD OF SPEECH LANGUAGE PATHOLOGY LICENSE