Provider Demographics
NPI:1669087664
Name:THORSON, ROBERT (PT, DPT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:THORSON
Suffix:
Gender:M
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 1:2433 W MAIN ST APT 298
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-7836
Mailing Address - Country:US
Mailing Address - Phone:630-777-2667
Mailing Address - Fax:
Practice Address - Street 1:11411 N 19TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-3642
Practice Address - Country:US
Practice Address - Phone:602-256-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-31301225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist