Provider Demographics
NPI:1639724271
Name:ROBERTS, DENISE MICHELE (PT)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:MICHELE
Last Name:ROBERTS
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 1:1142 N SNEAD PL
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6529
Mailing Address - Country:US
Mailing Address - Phone:208-941-3394
Mailing Address - Fax:
Practice Address - Street 1:1142 N SNEAD PL
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6529
Practice Address - Country:US
Practice Address - Phone:208-941-3394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1546225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist