Provider Demographics
NPI:1114366358
Name:BASSHAM, REBECCA A (BS, RT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:BASSHAM
Suffix:
Gender:F
Credentials:BS, RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2277 SWANSON AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5991
Mailing Address - Country:US
Mailing Address - Phone:928-486-5414
Mailing Address - Fax:928-854-0112
Practice Address - Street 1:2277 SWANSON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5991
Practice Address - Country:US
Practice Address - Phone:928-486-5414
Practice Address - Fax:928-854-0112
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No174H00000XOther Service ProvidersHealth Educator