Provider Demographics
NPI:1720170905
Name:METTAM, ROBERT NIE (PT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:NIE
Last Name:METTAM
Suffix:
Gender:M
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:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:CASTAIC
Mailing Address - State:CA
Mailing Address - Zip Code:91310-0278
Mailing Address - Country:US
Mailing Address - Phone:818-789-3819
Mailing Address - Fax:818-789-3546
Practice Address - Street 1:14116 MAGNOLIA BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-1119
Practice Address - Country:US
Practice Address - Phone:818-789-3819
Practice Address - Fax:818-789-3546
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT6855225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR37284Medicare UPIN
CAWPT6855AMedicare ID - Type UnspecifiedROBERT N. METTAM