Provider Demographics
NPI:1649927476
Name:ROBERSON, RAELYN LOISELLE (PHD)
Entity type:Individual
Prefix:
First Name:RAELYN
Middle Name:LOISELLE
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2512 LAKEVALE DR
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22181-4028
Mailing Address - Country:US
Mailing Address - Phone:518-223-2667
Mailing Address - Fax:
Practice Address - Street 1:1313 VINCENT PL
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3615
Practice Address - Country:US
Practice Address - Phone:501-295-7119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-02
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810008683103TC2200X
NY025822103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent