Provider Demographics
NPI:1811060197
Name:CASEY, ROBERTA H (PT, MS)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:H
Last Name:CASEY
Suffix:
Gender:F
Credentials:PT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 RIVER POINT DR
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-8791
Mailing Address - Country:US
Mailing Address - Phone:404-433-4223
Mailing Address - Fax:
Practice Address - Street 1:30A&B SAMFORD AVENUE
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801
Practice Address - Country:US
Practice Address - Phone:334-756-1126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4647225100000X
GA5181225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00071345CMedicaid
GA00071345COtherPEACH STATE