Provider Demographics
NPI:1912971169
Name:ROBERTSON, JOHN SCOTT (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:SCOTT
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5215 79TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-2832
Mailing Address - Country:US
Mailing Address - Phone:806-792-4713
Mailing Address - Fax:806-793-0231
Practice Address - Street 1:5215 79TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-2832
Practice Address - Country:US
Practice Address - Phone:806-792-4713
Practice Address - Fax:806-793-0231
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-4294103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00H25RMedicare ID - Type UnspecifiedMEDICARE