Provider Demographics
NPI:1275180671
Name:ROBERTSON, MEGAN (DPT)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5842 N WAYNE AVE APT G
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-1981
Mailing Address - Country:US
Mailing Address - Phone:608-444-9146
Mailing Address - Fax:
Practice Address - Street 1:4753 N BROADWAY ST STE 1014
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4990
Practice Address - Country:US
Practice Address - Phone:608-444-9146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070024296225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist