Healthcare Provider Details

I. General information

NPI: 1679658140
Provider Name (Legal Business Name): MICHAEL ALAN ROBERTSON OTR/L , CHT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 03/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVENUE
TACOMA WA
98431
US

IV. Provider business mailing address

9040 JACKSON AVENUE
TACOMA WA
98431-0001
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-6514
  • Fax:
Mailing address:
  • Phone: 253-968-6514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License NumberOTT002433
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: