Provider Demographics
NPI:1962290445
Name:ROBERTSON, OSA LEE
Entity type:Individual
Prefix:
First Name:OSA
Middle Name:LEE
Last Name:ROBERTSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 MARION COUNTY RD LOT 116
Mailing Address - Street 2:
Mailing Address - City:WEIRSDALE
Mailing Address - State:FL
Mailing Address - Zip Code:32195-5107
Mailing Address - Country:US
Mailing Address - Phone:484-764-6521
Mailing Address - Fax:
Practice Address - Street 1:200 CLUBHOUSE VISTA RD
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:FL
Practice Address - Zip Code:32702-9639
Practice Address - Country:US
Practice Address - Phone:800-343-1588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-25
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL05119224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant