Healthcare Provider Details

I. General information

NPI: 1780904995
Provider Name (Legal Business Name): DANIEL THOMAS ROBERTS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 06/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

168 MASSACHUSETTS AVE # SS 2890
BOSTON MA
02115-3010
US

IV. Provider business mailing address

168 MASSACHUSETTS AVE # SS 2890
BOSTON MA
02115-3010
US

V. Phone/Fax

Practice location:
  • Phone: 302-632-3432
  • Fax:
Mailing address:
  • Phone: 302-632-3432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number8182
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: