Provider Demographics
NPI:1194953281
Name:WALDROOP, BOBBIE JUNE
Entity type:Individual
Prefix:
First Name:BOBBIE
Middle Name:JUNE
Last Name:WALDROOP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BOBBIE
Other - Middle Name:JUNE
Other - Last Name:WALDROOP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:34 LLOYD TRL
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-5836
Mailing Address - Country:US
Mailing Address - Phone:386-597-3854
Mailing Address - Fax:
Practice Address - Street 1:350 S RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-7028
Practice Address - Country:US
Practice Address - Phone:986-677-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21308225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant