Provider Demographics
NPI:1033476536
Name:ROBERTSON, NICOLE M (MT)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:M
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3871 SUNSHINE TRL
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-9211
Mailing Address - Country:US
Mailing Address - Phone:248-310-5617
Mailing Address - Fax:
Practice Address - Street 1:3871 SUNSHINE TRL
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-9211
Practice Address - Country:US
Practice Address - Phone:248-310-5617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-20
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist