Provider Demographics
NPI:1174720528
Name:TISDALL, ROBERT B (DPT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:B
Last Name:TISDALL
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 1:10334 SPRINGDALE AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-0733
Mailing Address - Country:US
Mailing Address - Phone:225-754-2974
Mailing Address - Fax:
Practice Address - Street 1:28977 WALKER SOUTH ROAD
Practice Address - Street 2:STE G
Practice Address - City:WALKER
Practice Address - State:LA
Practice Address - Zip Code:70785
Practice Address - Country:US
Practice Address - Phone:225-271-8056
Practice Address - Fax:225-767-8757
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07062225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist