1770507469 NPI number — HEATHER ROBERTS PT

Table of content: HEATHER ROBERTS PT (NPI 1770507469)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770507469 NPI number — HEATHER ROBERTS PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTS
Provider First Name:
HEATHER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770507469
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1235
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODSTOCK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12498-8235
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-679-9767
Provider Business Mailing Address Fax Number:
845-679-2604

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2568 ROUTE 212
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODSTOCK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12498-2132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-679-9767
Provider Business Practice Location Address Fax Number:
845-679-2604
Provider Enumeration Date:
07/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  014531-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10096311 . This is a "CDPHP PROVIDER NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 603426 . This is a "MVP PROVIDER NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 89756 . This is a "GHI PROVIDER NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: Q16R71 . This is a "EMPIRE BC/BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02250402 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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