Provider Demographics
NPI:1265703243
Name:REVOLT, ROBERT JOHN (PTA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOHN
Last Name:REVOLT
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 1:11204 COVENTRY GREENS DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-3409
Mailing Address - Country:US
Mailing Address - Phone:502-708-1124
Mailing Address - Fax:
Practice Address - Street 1:2200 STONY BROOK DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-4016
Practice Address - Country:US
Practice Address - Phone:502-495-6240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA00571225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant