Provider Demographics
NPI:1720676323
Name:ROBERTSON, BO DEAN
Entity Type:Individual
Prefix:
First Name:BO
Middle Name:DEAN
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 1:1983 SPRING RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-9800
Mailing Address - Country:US
Mailing Address - Phone:808-352-3073
Mailing Address - Fax:
Practice Address - Street 1:483 N AVIATION BLVD BLDG 210
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-2808
Practice Address - Country:US
Practice Address - Phone:310-653-6860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-08
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist