Provider Demographics
NPI:1891162822
Name:ROBERTS, WADE (DPT, PT)
Entity Type:Individual
Prefix:DR
First Name:WADE
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3309 WYNRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-8404
Mailing Address - Country:US
Mailing Address - Phone:217-440-5762
Mailing Address - Fax:
Practice Address - Street 1:3309 WYNRIDGE RD
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-8404
Practice Address - Country:US
Practice Address - Phone:217-440-5762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.021685225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist