Healthcare Provider Details

I. General information

NPI: 1386806958
Provider Name (Legal Business Name): ROXANNE SMALL PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 E PAGE AVE
GILBERT AZ
85234-6212
US

IV. Provider business mailing address

2101 E PAGE AVE
GILBERT AZ
85234-6212
US

V. Phone/Fax

Practice location:
  • Phone: 480-231-7534
  • Fax:
Mailing address:
  • Phone: 480-231-7534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number503
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: