Provider Demographics
NPI:1205057858
Name:ROBERTS, STACI CATHY-SUE (PTA)
Entity type:Individual
Prefix:MISS
First Name:STACI
Middle Name:CATHY-SUE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11300 NW 90 AVE
Mailing Address - Street 2:
Mailing Address - City:REDDICK
Mailing Address - State:FL
Mailing Address - Zip Code:32686
Mailing Address - Country:US
Mailing Address - Phone:352-622-2570
Mailing Address - Fax:
Practice Address - Street 1:1525 HERBERT ST
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129
Practice Address - Country:US
Practice Address - Phone:386-756-0424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA20841225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTA20841OtherLICENSURE