Provider Demographics
NPI:1083789077
Name:ROBERTS, THERESA (PT, MOMT)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PT, MOMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16550 VENTURA BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2040
Mailing Address - Country:US
Mailing Address - Phone:818-905-1331
Mailing Address - Fax:818-905-8836
Practice Address - Street 1:16550 VENTURA BLVD STE 400
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2040
Practice Address - Country:US
Practice Address - Phone:818-905-1331
Practice Address - Fax:818-905-8836
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10281225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT10281AMedicare ID - Type Unspecified