Provider Demographics
NPI:1982700019
Name:ROBERTS, ANDREW MARK (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:MARK
Last Name:ROBERTS
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 1:1203 QUAIL DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408
Mailing Address - Country:US
Mailing Address - Phone:336-574-0404
Mailing Address - Fax:336-545-5566
Practice Address - Street 1:415 N EDGEWORTH ST
Practice Address - Street 2:SUITE 206
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-2182
Practice Address - Country:US
Practice Address - Phone:336-574-0404
Practice Address - Fax:336-545-5566
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0851103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107146Medicaid