Basic Information
| Provider Information | |||||||||
| NPI: | 1811205339 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTSON | ||||||||
| FirstName: | JOANNE | ||||||||
| MiddleName: | GALLO | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 42 S. DELSEA DRIVE | ||||||||
| Address2: | |||||||||
| City: | GLASSBORO | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568818689 | ||||||||
| FaxNumber: | 8568817614 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 RONNIE CT COASTAL HAVEN COUNSELING | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9439450346 | ||||||||
| FaxNumber: | 8568817614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2010 | ||||||||
| LastUpdateDate: | 08/19/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 37PC00383000 | NJ | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.