Basic Information
| Provider Information | |||||||||
| NPI: | 1124148051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | SHAYNA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ALT | ||||||||
| OtherFirstName: | SHAYNA | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6914 HOLABIRD AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212221747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102845441 | ||||||||
| FaxNumber: | 4102845442 | ||||||||
| Practice Location | |||||||||
| Address1: | 6914 HOLABIRD AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212221747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102845441 | ||||||||
| FaxNumber: | 4102845442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2007 | ||||||||
| LastUpdateDate: | 11/12/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 22109 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 201193079 | 01 | MD | TAX ID | OTHER |