Provider Demographics
NPI:1093825960
Name:MCCRACKEN, REBECCA CRISTINE (DPT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:CRISTINE
Last Name:MCCRACKEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 YORKTOWNE BLVD
Mailing Address - Street 2:APT 5802
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-6008
Mailing Address - Country:US
Mailing Address - Phone:386-562-7233
Mailing Address - Fax:
Practice Address - Street 1:900 N SWALLOWTAIL DR
Practice Address - Street 2:SUITE 107
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-6102
Practice Address - Country:US
Practice Address - Phone:386-322-4641
Practice Address - Fax:386-322-4677
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21556225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686716Medicare ID - Type Unspecified