Provider Demographics
NPI:1295883619
Name:ROBERTSON, GARY B (MS, LMFT)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:B
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9404 GENESEE AVE
Mailing Address - Street 2:SUITE 335
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1339
Mailing Address - Country:US
Mailing Address - Phone:858-755-9996
Mailing Address - Fax:858-587-1142
Practice Address - Street 1:9404 GENESEE AVE
Practice Address - Street 2:SUITE 335
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1339
Practice Address - Country:US
Practice Address - Phone:858-755-9996
Practice Address - Fax:858-587-1142
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 39996106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist