Provider Demographics
NPI:1336201342
Name:ROBERTS, MARK WEST (PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WEST
Last Name:ROBERTS
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 1:536 S 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5311
Mailing Address - Country:US
Mailing Address - Phone:208-478-4670
Mailing Address - Fax:
Practice Address - Street 1:921 S 8TH AVE
Practice Address - Street 2:GARRISON HALL 525 STOP 8021
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-0002
Practice Address - Country:US
Practice Address - Phone:208-282-2129
Practice Address - Fax:208-282-5411
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-138103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent