Provider Demographics
NPI:1740619766
Name:ROBERTSON, SHAVON D (DPT)
Entity Type:Individual
Prefix:
First Name:SHAVON
Middle Name:D
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12101 CAROL LN
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-6101
Mailing Address - Country:US
Mailing Address - Phone:540-785-7617
Mailing Address - Fax:540-786-8620
Practice Address - Street 1:12101 CAROL LN
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-6101
Practice Address - Country:US
Practice Address - Phone:540-785-7617
Practice Address - Fax:540-786-8620
Is Sole Proprietor?:No
Enumeration Date:2013-11-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305207820225100000X
MD24745225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist