MEDICARE: DEZIRAE ROBINSON DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	2297040401	MI
2	225100000X	Physical Therapist		TX

General Provider Information

NPI Number	:	1669116406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEZIRAE ROBINSON DPT

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	17220 N RM 620 RD STE 110
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78681-3913
Country	:	US
Telephone Number	:	512-527-6007
Fax Number	:	512-399-2287

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2022
Last Update Date	:	08/07/2024

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