Provider Demographics
NPI:1063668739
Name:ROBERSON, JOELLE MIRANDA (MS, PT)
Entity Type:Individual
Prefix:MRS
First Name:JOELLE
Middle Name:MIRANDA
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 N ELLICOTT ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5535
Mailing Address - Country:US
Mailing Address - Phone:716-631-0215
Mailing Address - Fax:
Practice Address - Street 1:98 N ELLICOTT ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5535
Practice Address - Country:US
Practice Address - Phone:716-631-0215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-14
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0117502251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics