Provider Demographics
NPI:1003561119
Name:FORTUNE, REBECCA DIANE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:DIANE
Last Name:FORTUNE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:DIANE
Other - Last Name:COFFMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:1208 WICKFORD PL
Mailing Address - Street 2:
Mailing Address - City:HURON
Mailing Address - State:OH
Mailing Address - Zip Code:44839-1467
Mailing Address - Country:US
Mailing Address - Phone:419-602-7153
Mailing Address - Fax:
Practice Address - Street 1:2025 HAYES AVE
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-4739
Practice Address - Country:US
Practice Address - Phone:419-627-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-16
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT-3097225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist