Provider Demographics
NPI:1073923470
Name:ROBERTS, MARISE AKEMI (MPT)
Entity Type:Individual
Prefix:
First Name:MARISE
Middle Name:AKEMI
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:MARISE
Other - Middle Name:AKEMI
Other - Last Name:ISHIZUKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4081 PARK CENTER LN APT B
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-2108
Mailing Address - Country:US
Mailing Address - Phone:510-861-8102
Mailing Address - Fax:
Practice Address - Street 1:4081 PARK CENTER LN APT B
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-2108
Practice Address - Country:US
Practice Address - Phone:510-861-8102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-07
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40980225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist