Provider Demographics
NPI:1164565354
Name:ROBERTSON, DIANE LOUISE (PT, MTC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:LOUISE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:PT, MTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8508 MOON GLASS CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-5630
Mailing Address - Country:US
Mailing Address - Phone:410-992-4146
Mailing Address - Fax:
Practice Address - Street 1:6801 DOUGLAS LEGUM DR
Practice Address - Street 2:SUITE B
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075-6273
Practice Address - Country:US
Practice Address - Phone:410-799-0818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16845208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD981L589EMedicare ID - Type Unspecified