Provider Demographics
NPI:1043940943
Name:ST.AMANT, REBECCA ANN
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:ANN
Last Name:ST.AMANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5221 AGAVE WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76126-3040
Mailing Address - Country:US
Mailing Address - Phone:817-905-9397
Mailing Address - Fax:
Practice Address - Street 1:3524 N CRUMP ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76106-4420
Practice Address - Country:US
Practice Address - Phone:817-815-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109235235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX659249401Medicaid