Provider Demographics
NPI:1861783383
Name:ROBERTSON, MELISSA JEAN (PTA)
Entity type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:JEAN
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S ARDMORE AVE APT 402
Mailing Address - Street 2:402
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-4904
Mailing Address - Country:US
Mailing Address - Phone:574-514-8341
Mailing Address - Fax:
Practice Address - Street 1:3703 W LAKE AVE
Practice Address - Street 2:200
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-1223
Practice Address - Country:US
Practice Address - Phone:847-998-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-02
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.004563225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant