1972076818 NPI number — PHYLLIS MARY ROBERTSON BA, MA CCC-SLP

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 1972076818 NPI number — PHYLLIS MARY ROBERTSON BA, MA CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTSON
Provider First Name:
PHYLLIS
Provider Middle Name:
MARY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BA, MA CCC-SLP
Provider Gender Code:
F

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:
1972076818
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
37 POPLAR AVE.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAULT STE. MARIE
Provider Business Mailing Address State Name:
ONTARIO
Provider Business Mailing Address Postal Code:
P6B 2W6
Provider Business Mailing Address Country Code:
CA
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
37 POPLAR AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAULT STE. MARIE
Provider Business Practice Location Address State Name:
ONTARIO
Provider Business Practice Location Address Postal Code:
P6B 2W6
Provider Business Practice Location Address Country Code:
CA
Provider Business Practice Location Address Telephone Number:
705-255-2868
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/03/2019

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: 235Z00000X , with the licence number:  7101003599 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: 22007955A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 22007955A . This is a "INDIANA PROFESSIONAL LICENSING AGENCY" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 7101003599 . This is a "BOARD OF SPEECH LANGUAGE PATHOLOGY LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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