Provider Demographics
NPI:1700934205
Name:ROBERTSON, NELTON J
Entity Type:Individual
Prefix:
First Name:NELTON
Middle Name:J
Last Name:ROBERTSON
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 1:4477 WEST 118TH ST
Mailing Address - Street 2:STE 103
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250
Mailing Address - Country:US
Mailing Address - Phone:310-644-7284
Mailing Address - Fax:310-644-7222
Practice Address - Street 1:4477 WEST 118TH ST
Practice Address - Street 2:STE 103
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250
Practice Address - Country:US
Practice Address - Phone:310-644-7284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA3141237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHA0031410Medicaid