Healthcare Provider Details

I. General information

NPI: 1689906489
Provider Name (Legal Business Name): AJA ROBISON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2010
Last Update Date: 03/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

379 PINEHAVEN STREET EXT
LAURENS SC
29360-2672
US

IV. Provider business mailing address

101 CLAY ST APT 101
CLINTON SC
29325-2372
US

V. Phone/Fax

Practice location:
  • Phone: 864-984-6584
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number60003452A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: