1790875789 NPI number — MR. DALE LILIIAN ROBERTS MENTAL HEALTH LICENS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790875789 NPI number — MR. DALE LILIIAN ROBERTS MENTAL HEALTH LICENS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTS
Provider First Name:
DALE
Provider Middle Name:
LILIIAN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MENTAL HEALTH LICENS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790875789
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7333 SW 137TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARCHER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32618-5831
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-495-9138
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 SW ARCHER RD
Provider Second Line Business Practice Location Address:
VA MEDICAL CENTER, PSYCHOLOGY SERVICE 116-B
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32608-1135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-376-1611
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  000916 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)