Provider Demographics
NPI:1740531904
Name:ROBERTS, ALLISON (OTR/L)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 IDAHO ST
Mailing Address - Street 2:PO BOX 719
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-1965
Mailing Address - Country:US
Mailing Address - Phone:208-799-5219
Mailing Address - Fax:
Practice Address - Street 1:1250 IDAHO ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-1965
Practice Address - Country:US
Practice Address - Phone:208-799-5219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-27
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60286464225X00000X
IDOT-1048225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
911031583Medicare PIN