Healthcare Provider Details

I. General information

NPI: 1073547857
Provider Name (Legal Business Name): SCOTT JONATHAN ROBERTS MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3514 MAYLAND CT
RICHMOND VA
23233-1421
US

IV. Provider business mailing address

3514 MAYLAND CT
RICHMOND VA
23233-1421
US

V. Phone/Fax

Practice location:
  • Phone: 804-747-0003
  • Fax: 804-747-0043
Mailing address:
  • Phone: 804-747-0003
  • Fax: 804-747-0043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0019004823
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number2305203258
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number2305203258
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: