Provider Demographics
NPI:1174042766
Name:ROBERTSON, TRAVIS WADE (DPT)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:WADE
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10909-11 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:IL
Mailing Address - Zip Code:60643
Mailing Address - Country:US
Mailing Address - Phone:773-779-7970
Mailing Address - Fax:773-779-7969
Practice Address - Street 1:10909-11 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:IL
Practice Address - Zip Code:60643
Practice Address - Country:US
Practice Address - Phone:773-779-7970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070023168225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist