Basic Information
| Provider Information | |||||||||
| NPI: | 1891751087 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBERTSON | ||||||||
| FirstName: | EDDY | ||||||||
| MiddleName: | LEONARD | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 803 LINE STREET | ||||||||
| Address2: | BOX 28 | ||||||||
| City: | COLTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092293979 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1620 SE SUMMIT CT | ||||||||
| Address2: | |||||||||
| City: | PULLMAN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 991635519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093325106 | ||||||||
| FaxNumber: | 5093345723 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00007122 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.