Healthcare Provider Details

I. General information

NPI: 1578045324
Provider Name (Legal Business Name): TASIA ROBERTSON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2018
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5507 MILL RACE CIR
PACE FL
32571-6441
US

IV. Provider business mailing address

5507 MILL RACE CIR
PACE FL
32571-6441
US

V. Phone/Fax

Practice location:
  • Phone: 801-400-3328
  • Fax:
Mailing address:
  • Phone: 801-400-3328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT32726
License Number StateFL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100767600
Identifier TypeMEDICAID
Identifier StateFL
Identifier IssuerFlorida Medicaid Provider ID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: