Provider Demographics
NPI:1891751087
Name:ROBERTSON, EDDY LEONARD (PT)
Entity Type:Individual
Prefix:
First Name:EDDY
Middle Name:LEONARD
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 LINE STREET
Mailing Address - Street 2:BOX 28
Mailing Address - City:COLTON
Mailing Address - State:WA
Mailing Address - Zip Code:99113
Mailing Address - Country:US
Mailing Address - Phone:509-229-3979
Mailing Address - Fax:
Practice Address - Street 1:1620 SE SUMMIT CT
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5519
Practice Address - Country:US
Practice Address - Phone:509-332-5106
Practice Address - Fax:509-334-5723
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007122225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist