Provider Demographics
NPI:1972946556
Name:ROBERTS, BRIAN CLIFFORD (ATC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:CLIFFORD
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:PA
Mailing Address - Zip Code:18810-1723
Mailing Address - Country:US
Mailing Address - Phone:570-888-0818
Mailing Address - Fax:
Practice Address - Street 1:526 PANTHER LN
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:PA
Practice Address - Zip Code:18837-7892
Practice Address - Country:US
Practice Address - Phone:570-744-2521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-12
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPROVIDER CODE 22OtherPROVIDER CODE 22 (RESPIRATORY, REHABILITATIVE & RESTORATIVE SERVICE PROVIDERS)