Provider Demographics
NPI:1063428134
Name:ROBERTSON, GRACEANN MARY (PHD)
Entity type:Individual
Prefix:
First Name:GRACEANN
Middle Name:MARY
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7150 KALAMAZOO AVE SE STE C
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316-9197
Mailing Address - Country:US
Mailing Address - Phone:616-219-0159
Mailing Address - Fax:616-219-0124
Practice Address - Street 1:7150 KALAMAZOO AVE SE STE C
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-9197
Practice Address - Country:US
Practice Address - Phone:616-219-0159
Practice Address - Fax:616-219-0124
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008866103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
680D117560OtherBCBS
680D117560OtherBCBS
MIS17505Medicare UPIN