Provider Demographics
NPI:1437195195
Name:ROBERTS, CONNIE ALLENE (PT)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:ALLENE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:CONNIE
Other - Middle Name:ROBERTS
Other - Last Name:PETTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2415 MCCALLIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-3322
Mailing Address - Country:US
Mailing Address - Phone:423-624-2696
Mailing Address - Fax:423-697-2025
Practice Address - Street 1:2415 MCCALLIE AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-3322
Practice Address - Country:US
Practice Address - Phone:423-624-2696
Practice Address - Fax:423-697-2025
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN0000001866225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0088962OtherBLUE CROSS/ BLUE SHIELD
TNTN0120OtherJOHN DEERE
TNTN0120OtherJOHN DEERE