Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103TC1900X | Counseling Psychologist | 767 | KS |
Y | 103TC1900X | Counseling Psychologist | KS#767 | KS |
NPI | 1013918796 |
---|---|
Provider Name | Mr. John M Robertson |
First Address | Lawrence, KS 66049-3832 |
Second Address | Lawrence, KS 66049-3832 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/08/2005 |
Last Update Date | 18/12/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100239800A | (05) | KS |
R31097 | (02) | KS |