Provider Demographics
NPI:1013918796
Name:ROBERTSON, JOHN M (PHD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:M
Last Name:ROBERTSON
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 1:1441 WAKARUSA DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-3832
Mailing Address - Country:US
Mailing Address - Phone:785-840-9820
Mailing Address - Fax:785-841-8016
Practice Address - Street 1:1441 WAKARUSA DR
Practice Address - Street 2:SUITE 200
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-3832
Practice Address - Country:US
Practice Address - Phone:785-840-9820
Practice Address - Fax:785-841-8016
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS767103TC1900X
KSKS#767103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100239800AMedicaid
KS100239800AMedicaid