Provider Demographics
NPI:1174544381
Name:ROBERSON, KENNETH (PHD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:ROBERSON
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 1:1700 PIERCE ST
Mailing Address - Street 2:SUITE 402
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-3108
Mailing Address - Country:US
Mailing Address - Phone:415-922-1122
Mailing Address - Fax:415-440-7436
Practice Address - Street 1:1700 PIERCE ST
Practice Address - Street 2:SUITE 402
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3108
Practice Address - Country:US
Practice Address - Phone:415-922-1122
Practice Address - Fax:415-440-7436
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11958103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist