Provider Demographics
NPI:1386053163
Name:ROBERSON, AMANDA (MAT, ATC, LAT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:MAT, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 S 103RD ST
Mailing Address - Street 2:300
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53227-4163
Mailing Address - Country:US
Mailing Address - Phone:262-366-3655
Mailing Address - Fax:262-565-4304
Practice Address - Street 1:3400 S 103RD ST
Practice Address - Street 2:300
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-4163
Practice Address - Country:US
Practice Address - Phone:262-366-3655
Practice Address - Fax:262-565-4304
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1591-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer