Provider Demographics
NPI:1427070622
Name:ROBERTS, BRETT (DPT)
Entity type:Individual
Prefix:MR
First Name:BRETT
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 324
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:WI
Mailing Address - Zip Code:54406-0324
Mailing Address - Country:US
Mailing Address - Phone:715-529-3487
Mailing Address - Fax:715-251-6236
Practice Address - Street 1:167 N MAIN ST
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:WI
Practice Address - Zip Code:54406-9028
Practice Address - Country:US
Practice Address - Phone:715-529-3487
Practice Address - Fax:715-251-6236
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1033-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40384900Medicaid
WI202942458012OtherBC/BS GROUP ID
WIP00305551OtherRAILROAD MEDICARE IND ID
WIP00305551OtherRAILROAD MEDICARE IND ID
WI202942458OtherEIN
WIP84000Medicare UPIN