Provider Demographics
NPI:1770014995
Name:ROBERTS, TANYA (PT)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829-1276
Mailing Address - Country:US
Mailing Address - Phone:906-789-2404
Mailing Address - Fax:906-789-2405
Practice Address - Street 1:501 S LINCOLN RD
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1276
Practice Address - Country:US
Practice Address - Phone:906-789-2404
Practice Address - Fax:906-789-2405
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012624225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist