Provider Demographics
NPI:1689961930
Name:ROBERTS, VICTOR DEMOND (LMT)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:DEMOND
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 HOLLISTER ST APT 2909
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77040-6879
Mailing Address - Country:US
Mailing Address - Phone:281-546-7776
Mailing Address - Fax:
Practice Address - Street 1:5959 WEST LOOP S STE 365
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401-2421
Practice Address - Country:US
Practice Address - Phone:281-546-7776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-07
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103629225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist