Provider Demographics
NPI:1437310257
Name:ROBERTS, MATTHEW (PTA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12960 DARTFORD TRL
Mailing Address - Street 2:#9
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-3982
Mailing Address - Country:US
Mailing Address - Phone:770-778-7482
Mailing Address - Fax:
Practice Address - Street 1:12960 DARTFORD TRL
Practice Address - Street 2:#9
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-3982
Practice Address - Country:US
Practice Address - Phone:770-778-7482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 19868225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant