Provider Demographics
NPI:1871141028
Name:ROBERTSON, SHAWNA (LMT)
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:762 INDEPENDENCE BLVD STE 100C
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-6250
Mailing Address - Country:US
Mailing Address - Phone:757-268-6211
Mailing Address - Fax:
Practice Address - Street 1:762 INDEPENDENCE BLVD STE 100C
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-6250
Practice Address - Country:US
Practice Address - Phone:757-268-6211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-30
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019005740225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist