Provider Demographics
NPI:1659842607
Name:ROBINSON, GERVONIA
Entity type:Individual
Prefix:
First Name:GERVONIA
Middle Name:
Last Name:ROBINSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13906 BALLANTYNE MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-3727
Mailing Address - Country:US
Mailing Address - Phone:984-221-1140
Mailing Address - Fax:803-630-0376
Practice Address - Street 1:1714 ASTER LN
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-8303
Practice Address - Country:US
Practice Address - Phone:984-221-1140
Practice Address - Fax:803-630-0376
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children