Provider Demographics
NPI:1184054827
Name:ROBERSON, CRAIG (LMT)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:ROBERSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:753 SE PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984-5211
Mailing Address - Country:US
Mailing Address - Phone:772-249-6451
Mailing Address - Fax:
Practice Address - Street 1:753 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34984-5211
Practice Address - Country:US
Practice Address - Phone:772-249-6451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-15
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA73373225700000X
FLMM31067225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist