Provider Demographics
NPI:1649769134
Name:BECKSTEAD, ROBERT MITCHELL (DPT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MITCHELL
Last Name:BECKSTEAD
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 YELLOWSTONE AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4511
Mailing Address - Country:US
Mailing Address - Phone:208-478-1488
Mailing Address - Fax:208-478-1498
Practice Address - Street 1:675 YELLOWSTONE AVE STE 1
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4511
Practice Address - Country:US
Practice Address - Phone:208-478-1488
Practice Address - Fax:208-478-1498
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-5647225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPT-5647OtherSTATE LICENSE