Provider Demographics
NPI:1083294466
Name:REBURN, JUDITH DARLENE (OTR)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:DARLENE
Last Name:REBURN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 S 12TH ST
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74021-3511
Mailing Address - Country:US
Mailing Address - Phone:810-429-2517
Mailing Address - Fax:
Practice Address - Street 1:713 S 12TH ST
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:OK
Practice Address - Zip Code:74021-3511
Practice Address - Country:US
Practice Address - Phone:810-429-2517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-10
Last Update Date:2021-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5271225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist