Provider Demographics
NPI:1114905254
Name:REEBERG, CARLOS RAOUL (PT)
Entity Type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:RAOUL
Last Name:REEBERG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 S GILBERT RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-4442
Mailing Address - Country:US
Mailing Address - Phone:480-507-0130
Mailing Address - Fax:480-507-0135
Practice Address - Street 1:1017 S GILBERT RD
Practice Address - Street 2:SUITE 104
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-4442
Practice Address - Country:US
Practice Address - Phone:480-507-0130
Practice Address - Fax:480-507-0135
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6440225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1114905254OtherNPPES
AZ1114905254OtherNPPES