Provider Demographics
NPI:1811196736
Name:ROBERTSON, GARY P (OTR)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:P
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 640277
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:FL
Mailing Address - Zip Code:34464-0277
Mailing Address - Country:US
Mailing Address - Phone:508-274-3321
Mailing Address - Fax:
Practice Address - Street 1:275 S ROCK CRUSHER RD
Practice Address - Street 2:LOT 371
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-5751
Practice Address - Country:US
Practice Address - Phone:508-274-3321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2008-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT9733225X00000X, 225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAH066Medicare PIN