Provider Demographics
NPI:1760727705
Name:ROBBERTS, SHANE EDWARD (PTA)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:EDWARD
Last Name:ROBBERTS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8030 OAK HILL RD NE
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:OH
Mailing Address - Zip Code:43107-9769
Mailing Address - Country:US
Mailing Address - Phone:740-503-2001
Mailing Address - Fax:
Practice Address - Street 1:920 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW LEXINGTON
Practice Address - State:OH
Practice Address - Zip Code:43764-1552
Practice Address - Country:US
Practice Address - Phone:740-342-5161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH07400225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant