Provider Demographics
NPI:1720248750
Name:ROBERTSON, CASEY J (ATC, LAT)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:J
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 N CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-3350
Mailing Address - Country:US
Mailing Address - Phone:573-368-0999
Mailing Address - Fax:573-368-2777
Practice Address - Street 1:906 N CEDAR ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-3350
Practice Address - Country:US
Practice Address - Phone:573-368-0999
Practice Address - Fax:573-368-2777
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040239262255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer