Provider Demographics
NPI:1861155426
Name:ROBERTSON, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 ELM ST STE 106H
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03101-1828
Mailing Address - Country:US
Mailing Address - Phone:603-600-1033
Mailing Address - Fax:
Practice Address - Street 1:55 MIDDLESEX ST STE 6
Practice Address - Street 2:
Practice Address - City:NORTH CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01863-1569
Practice Address - Country:US
Practice Address - Phone:603-600-1033
Practice Address - Fax:978-428-5811
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2282655363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000000OtherBLUE CROSS BLUE SHIELD
MA000000OtherOPTUM
MA000000OtherAETNA
MA000000OtherHARVARD PILGRIM
MA000000Medicaid