Provider Demographics
NPI:1003374216
Name:BRUNER, REBEKAH (PTA)
Entity Type:Individual
Prefix:MRS
First Name:REBEKAH
Middle Name:
Last Name:BRUNER
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 1:564 WELLINGTON LN
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-8525
Mailing Address - Country:US
Mailing Address - Phone:678-267-6905
Mailing Address - Fax:
Practice Address - Street 1:801 RIVERHILL DR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-4067
Practice Address - Country:US
Practice Address - Phone:706-369-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002985225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty