Provider Demographics
NPI:1881903631
Name:ROBERTSON, SUSAN RUTH (PH D)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:RUTH
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 W 22ND ST
Mailing Address - Street 2:5
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-2689
Mailing Address - Country:US
Mailing Address - Phone:212-627-2624
Mailing Address - Fax:
Practice Address - Street 1:25 FLATBUSH AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-1101
Practice Address - Country:US
Practice Address - Phone:718-875-1420
Practice Address - Fax:718-875-4596
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007507103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical