Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | PSY004453 | GA |
N | 103T00000X | Psychologist | PSY004453 | GA |
Y | 103TF0200X | Forensic Psychologist | PSY004453 | GA |
N | 103TH0100X | Health Service | PSY004453 | GA |
NPI | 1114594207 |
---|---|
Provider Name | Dr. Alyssa Roberson |
First Address | Pooler, GA 31322-6019 |
Second Address | Pooler, GA 31322-6019 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/06/2021 |
Last Update Date | 25/06/2021 |