Provider Demographics
NPI:1609088111
Name:GANOE, ROBERTA JUSTINE (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:JUSTINE
Last Name:GANOE
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1334 MAYS ROAD
Mailing Address - Street 2:
Mailing Address - City:BROOKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15825
Mailing Address - Country:US
Mailing Address - Phone:814-328-5239
Mailing Address - Fax:
Practice Address - Street 1:1334 MAYS ROAD
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:PA
Practice Address - Zip Code:15825
Practice Address - Country:US
Practice Address - Phone:814-328-5239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0C004155L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist