Provider Demographics
NPI:1689710584
Name:ROBERTS, MARY K (RPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18160 SIX TREES LN
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-8763
Mailing Address - Country:US
Mailing Address - Phone:719-491-0859
Mailing Address - Fax:
Practice Address - Street 1:2835 DUBLIN BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-1662
Practice Address - Country:US
Practice Address - Phone:719-533-1318
Practice Address - Fax:719-533-1319
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3507225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist