Provider Demographics
NPI:1205955317
Name:ROBERSON, SUSAN G (PT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:G
Last Name:ROBERSON
Suffix:
Gender:F
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:PO BOX 501
Mailing Address - Street 2:1580 HWY 287 N
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-0501
Mailing Address - Country:US
Mailing Address - Phone:817-473-4684
Mailing Address - Fax:817-473-1170
Practice Address - Street 1:1580 HIGHWAY 287 N
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-7593
Practice Address - Country:US
Practice Address - Phone:817-473-4684
Practice Address - Fax:817-473-1170
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1035244225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX650416Medicare ID - Type Unspecified