Healthcare Provider Details

I. General information

NPI: 1881697597
Provider Name (Legal Business Name): ROBERT COREY ADDICOTT P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20325 N 51ST AVE STE 150
GLENDALE AZ
85308-4622
US

IV. Provider business mailing address

18444 N 25TH AVE SUITE 310
PHOENIX AZ
85023-1261
US

V. Phone/Fax

Practice location:
  • Phone: 602-385-2115
  • Fax: 480-418-3323
Mailing address:
  • Phone: 623-537-5600
  • Fax: 866-939-2673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5198
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number5198
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number5198
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: