Provider Demographics
NPI:1649752700
Name:ROBERTS, DYLAN
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6448 LAKESHORE RD
Mailing Address - Street 2:
Mailing Address - City:BURTCHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48059-2557
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6448 LAKESHORE RD
Practice Address - Street 2:
Practice Address - City:BURTCHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48059-2557
Practice Address - Country:US
Practice Address - Phone:810-300-5401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501018799225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist