Provider Demographics
NPI:1316969231
Name:ROBERTSON, MICHELLE (PT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:ROBERTSON
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 1:19215 PENINSULA SHORES DR
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-7579
Mailing Address - Country:US
Mailing Address - Phone:704-895-7343
Mailing Address - Fax:
Practice Address - Street 1:19215 PENINSULA SHORES DR
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-7579
Practice Address - Country:US
Practice Address - Phone:704-895-7343
Practice Address - Fax:704-895-7343
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP5385225100000X, 2251P0200X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211650Medicaid