Provider Demographics
NPI:1083893879
Name:SUNDSTROM DEVINE, REBECCA L (PTA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:SUNDSTROM DEVINE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:S
Other - Last Name:DEVINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4560 SE INTERNATIONAL WAY
Mailing Address - Street 2:CONSONUS HEALTHCARE SERVICES SUITE 100
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222
Mailing Address - Country:US
Mailing Address - Phone:971-206-5149
Mailing Address - Fax:971-206-5209
Practice Address - Street 1:20400 SARATOGA LOS GATOS RD
Practice Address - Street 2:
Practice Address - City:SARATOGA
Practice Address - State:CA
Practice Address - Zip Code:95070-5927
Practice Address - Country:US
Practice Address - Phone:408-741-2983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT3277225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant