Provider Demographics
NPI:1306148622
Name:ROBERTS, KARI DIANE (PT)
Entity type:Individual
Prefix:MRS
First Name:KARI
Middle Name:DIANE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 WOLF CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2314
Mailing Address - Country:US
Mailing Address - Phone:618-239-9910
Mailing Address - Fax:
Practice Address - Street 1:12 WOLF CREEK DR
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2314
Practice Address - Country:US
Practice Address - Phone:618-239-9910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-18
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-016305225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01519522OtherRR MEDICARE
IL207465Medicare PIN