Provider Demographics
NPI:1477757904
Name:ROBERTSON, KEVIN C (AT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:C
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7235 S MERLYN PL
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-9533
Mailing Address - Country:US
Mailing Address - Phone:440-357-6677
Mailing Address - Fax:440-357-6681
Practice Address - Street 1:9930 JOHNNYCAKE RIDGE RD
Practice Address - Street 2:SUITE 6B
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6752
Practice Address - Country:US
Practice Address - Phone:440-357-6677
Practice Address - Fax:440-357-6681
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT21052255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer