Basic Information
| Provider Information | |||||||||
| NPI: | 1770988347 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBERGE | ||||||||
| FirstName: | KYLEE | ||||||||
| MiddleName: | JOY | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 582 OAK GROVE RD | ||||||||
| Address2: | |||||||||
| City: | VASSALBORO | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049893236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076603484 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5001 STATESMAN DR | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750632414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8772825613 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2014 | ||||||||
| LastUpdateDate: | 10/24/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 015061 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.