Provider Demographics
NPI:1508980053
Name:BURNEY, ROBERTA JEAN (PT)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:JEAN
Last Name:BURNEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 ENGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-3348
Mailing Address - Country:US
Mailing Address - Phone:770-461-5271
Mailing Address - Fax:770-969-1119
Practice Address - Street 1:110 BASTILLE WAY
Practice Address - Street 2:100
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7620
Practice Address - Country:US
Practice Address - Phone:770-461-5270
Practice Address - Fax:770-969-1119
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1439225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAS84554Medicare UPIN
GA65BBBDFMedicare ID - Type UnspecifiedPHYSICAL THERAPIST