Provider Demographics
NPI:1245448299
Name:ROBERTS, ELLEN B (PT)
Entity type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:B
Last Name:ROBERTS
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 1:1208 SE 12TH CIR
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64081-2176
Mailing Address - Country:US
Mailing Address - Phone:816-554-3231
Mailing Address - Fax:
Practice Address - Street 1:111 NW MOCK AVE
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-2503
Practice Address - Country:US
Practice Address - Phone:816-228-5655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORO702225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist