Provider Demographics
NPI:1134681703
Name:MAGOON, REBECCA L (CMT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:MAGOON
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8941 WILDWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ST BONIFACIUS
Mailing Address - State:MN
Mailing Address - Zip Code:55375-1124
Mailing Address - Country:US
Mailing Address - Phone:612-384-7651
Mailing Address - Fax:
Practice Address - Street 1:4725 EXCELSIOR BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-3043
Practice Address - Country:US
Practice Address - Phone:612-384-7651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist