Provider Demographics
NPI:1346465887
Name:ROBERTSON, LEO E III (PT)
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:E
Last Name:ROBERTSON
Suffix:III
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 N 1ST E
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:ID
Mailing Address - Zip Code:83263-1326
Mailing Address - Country:US
Mailing Address - Phone:208-852-4122
Mailing Address - Fax:208-852-7187
Practice Address - Street 1:134 S STATE ST
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:ID
Practice Address - Zip Code:83263
Practice Address - Country:US
Practice Address - Phone:208-852-4122
Practice Address - Fax:208-852-7187
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2026225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1346465887Medicaid
UTD5960Medicaid
IDPT-2026OtherPHYSICAL THERAPY LICENSE