Provider Demographics
NPI:1982838496
Name:SUPER, ROBERT MICHAEL (LAT, COF)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MICHAEL
Last Name:SUPER
Suffix:
Gender:M
Credentials:LAT, COF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5571 EASTON RD.
Mailing Address - Street 2:
Mailing Address - City:PIPERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18947
Mailing Address - Country:US
Mailing Address - Phone:410-845-3929
Mailing Address - Fax:
Practice Address - Street 1:1255 W 15TH ST STE 540
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-7248
Practice Address - Country:US
Practice Address - Phone:410-845-3929
Practice Address - Fax:972-767-3728
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-12
Last Update Date:2014-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOF000004225000000X
PART0057872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter