Provider Demographics
NPI:1568829745
Name:BURT, ROGER JAMES (LMP)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:JAMES
Last Name:BURT
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 N MOONSTONE ST
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-6176
Mailing Address - Country:US
Mailing Address - Phone:208-964-1585
Mailing Address - Fax:
Practice Address - Street 1:12727 W 14TH AVE
Practice Address - Street 2:
Practice Address - City:AIRWAY HEIGHTS
Practice Address - State:WA
Practice Address - Zip Code:99001-9409
Practice Address - Country:US
Practice Address - Phone:509-244-4818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-20
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60623287225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist