Provider Demographics
NPI:1467069468
Name:ROBERTSON, JOANNA PATRICIA (LMT)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:PATRICIA
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:953 E BLUE HERON ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-3463
Mailing Address - Country:US
Mailing Address - Phone:208-713-6425
Mailing Address - Fax:
Practice Address - Street 1:2596 N STOKESBERRY PL STE 130
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-6087
Practice Address - Country:US
Practice Address - Phone:208-713-6425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-3207225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist