Provider Demographics
NPI:1477393924
Name:ROBERTS, MESHACH B
Entity type:Individual
Prefix:
First Name:MESHACH
Middle Name:B
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 NEENAH CTR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3070
Mailing Address - Country:US
Mailing Address - Phone:920-831-5050
Mailing Address - Fax:
Practice Address - Street 1:1516 S COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-4802
Practice Address - Country:US
Practice Address - Phone:920-831-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-30
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3132775225100000X
WI17008225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist