Healthcare Provider Details

I. General information

NPI: 1316969231
Provider Name (Legal Business Name): MICHELLE ROBERTSON P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 06/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19215 PENINSULA SHORES DR
CORNELIUS NC
28031-7579
US

IV. Provider business mailing address

19215 PENINSULA SHORES DR
CORNELIUS NC
28031-7579
US

V. Phone/Fax

Practice location:
  • Phone: 704-895-7343
  • Fax: 704-895-7343
Mailing address:
  • Phone: 704-895-7343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberP5385
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP5385
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberP5385
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: