Provider Demographics
NPI:1003620634
Name:ROBERTS, DEVERRON (PTA)
Entity type:Individual
Prefix:
First Name:DEVERRON
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2423 S HOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93706-5038
Mailing Address - Country:US
Mailing Address - Phone:559-999-2597
Mailing Address - Fax:
Practice Address - Street 1:1756 11TH ST
Practice Address - Street 2:
Practice Address - City:REEDLEY
Practice Address - State:CA
Practice Address - Zip Code:93654-2904
Practice Address - Country:US
Practice Address - Phone:559-638-1171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-04
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53805225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant