Provider Demographics
NPI:1811017585
Name:ROBERTSON, VIRGINIA
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10541 VALENTINE RD S
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32317-8609
Mailing Address - Country:US
Mailing Address - Phone:850-877-8855
Mailing Address - Fax:
Practice Address - Street 1:3334 CAPITAL MEDICAL BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-8405
Practice Address - Country:US
Practice Address - Phone:850-877-8855
Practice Address - Fax:850-877-7627
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 30343225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist