Provider Demographics
NPI:1659621175
Name:ROBERTSON, HEATHER ELAINE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ELAINE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16289 LAKE OF EGYPT RD
Mailing Address - Street 2:
Mailing Address - City:CREAL SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:62922-3708
Mailing Address - Country:US
Mailing Address - Phone:618-889-3826
Mailing Address - Fax:
Practice Address - Street 1:2907 WILLIAMSON COUNTY PKWY
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5256
Practice Address - Country:US
Practice Address - Phone:618-998-9894
Practice Address - Fax:618-998-9993
Is Sole Proprietor?:No
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070019505225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist