Healthcare Provider Details

I. General information

NPI: 1770194789
Provider Name (Legal Business Name): BRANDI ROBERTSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2020
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4560 SE INTERNATIONAL WAY STE 100
MILWAUKIE OR
97222-4628
US

IV. Provider business mailing address

4560 SE INTERNATIONAL WAY STE 100
MILWAUKIE OR
97222-4628
US

V. Phone/Fax

Practice location:
  • Phone: 217-774-2111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.012473
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: