Provider Demographics
NPI:1902131584
Name:ROBERTSON, COREY L (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:L
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106 CARPATHIAN DR
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-4710
Mailing Address - Country:US
Mailing Address - Phone:407-716-7569
Mailing Address - Fax:
Practice Address - Street 1:2106 CARPATHIAN DR
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32712-4710
Practice Address - Country:US
Practice Address - Phone:407-716-7569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-15
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL693250998Medicaid
FL693250996Medicaid