Provider Demographics
NPI:1124682406
Name:ROBERSON, GREGORY LEE
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:LEE
Last Name:ROBERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 BENEDUM DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1503
Mailing Address - Country:US
Mailing Address - Phone:304-842-9887
Mailing Address - Fax:
Practice Address - Street 1:415 BENEDUM DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1503
Practice Address - Country:US
Practice Address - Phone:304-842-9887
Practice Address - Fax:304-842-9888
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV003284225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist