Provider Demographics
NPI:1295051738
Name:ROBERTSON, NICOLE CAMILLE (PT, DPT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:CAMILLE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11850 FREEDOM DR APT 709
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-6053
Mailing Address - Country:US
Mailing Address - Phone:210-687-0341
Mailing Address - Fax:
Practice Address - Street 1:21631 RIDGETOP CIR STE 225
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20166-4289
Practice Address - Country:US
Practice Address - Phone:571-207-8850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-08
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1184713225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1184713OtherLICENSE