Basic Information
Provider Information | |||||||||
NPI: | 1538594270 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROBERTSON | ||||||||
FirstName: | ANGELA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5480 BALTIMORE DR STE 250 | ||||||||
Address2: |   | ||||||||
City: | LA MESA | ||||||||
State: | CA | ||||||||
PostalCode: | 919422066 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6199174675 | ||||||||
FaxNumber: | 6193033306 | ||||||||
Practice Location | |||||||||
Address1: | 5480 BALTIMORE DR STE 250 | ||||||||
Address2: |   | ||||||||
City: | LA MESA | ||||||||
State: | CA | ||||||||
PostalCode: | 919422066 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6199174675 | ||||||||
FaxNumber: | 6193033306 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/12/2013 | ||||||||
LastUpdateDate: | 09/12/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 40712200 | CA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |   |
No ID Information.