Basic Information
| Provider Information | |||||||||
| NPI: | 1417155664 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | TRACI | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LICENSED PHYSICAL TH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SPRAKER | ||||||||
| OtherFirstName: | TRACI | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LICENSED PHYSICAL TH | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 342 VIRGINIA AVENUE | ||||||||
| Address2: | HEARTLAND REHABILITATION SERVICES OF VIRGINIA INC | ||||||||
| City: | WYTHEVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2762286200 | ||||||||
| FaxNumber: | 2762289175 | ||||||||
| Practice Location | |||||||||
| Address1: | 342 VIRGINIA AVENUE | ||||||||
| Address2: | HEARTLAND REHABILITATION SERVICES OF VIRGINIA INC | ||||||||
| City: | WYTHEVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2762286200 | ||||||||
| FaxNumber: | 2762289175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2007 | ||||||||
| LastUpdateDate: | 07/10/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2306001038 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.