Provider Demographics
NPI:1619062932
Name:ROBERTSON, HEATHER (PT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:ROBERTSON
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 1:130 LA PLACITA CIR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4009
Mailing Address - Country:US
Mailing Address - Phone:505-992-0211
Mailing Address - Fax:
Practice Address - Street 1:826 CAMINO DEL MONTE REY
Practice Address - Street 2:SUITE B3
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3977
Practice Address - Country:US
Practice Address - Phone:505-983-4882
Practice Address - Fax:505-983-9882
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1183225100000X, 2251G0304X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM00Q545OtherBLUE CROSS BLUE SHIELD
NM610375300OtherOWCP PROVIDER NUMBER