Provider Demographics
NPI:1396770434
Name:ROBERTSON, BRUCE J (PHD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:J
Last Name:ROBERTSON
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 1:2631 PACKERLAND DR
Mailing Address - Street 2:SUITE 104-C
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-4130
Mailing Address - Country:US
Mailing Address - Phone:920-965-7701
Mailing Address - Fax:920-497-4956
Practice Address - Street 1:2631 PACKERLAND DR
Practice Address - Street 2:SUITE 104-C
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-4130
Practice Address - Country:US
Practice Address - Phone:920-965-7701
Practice Address - Fax:920-497-4956
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2009-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1992-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39699400Medicaid
WI85206-0022Medicare ID - Type Unspecified