Provider Demographics
NPI:1063639052
Name:FORD, REBECCA L
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:L
Last Name:FORD
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 1:10806 E ROSEWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1144
Mailing Address - Country:US
Mailing Address - Phone:260-402-3359
Mailing Address - Fax:260-637-9945
Practice Address - Street 1:10806 E ROSEWOOD CIR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1144
Practice Address - Country:US
Practice Address - Phone:260-402-3359
Practice Address - Fax:260-637-9945
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22000966A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist