Provider Demographics
NPI:1144770397
Name:GUILLEN, REBECCA SOPHIA (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:SOPHIA
Last Name:GUILLEN
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:SOPHIA
Other - Last Name:HERR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC, LAT
Mailing Address - Street 1:2901 BUSCH LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-1860
Mailing Address - Country:US
Mailing Address - Phone:813-936-7979
Mailing Address - Fax:813-936-1600
Practice Address - Street 1:2901 BUSCH LAKE BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-1860
Practice Address - Country:US
Practice Address - Phone:813-936-7979
Practice Address - Fax:813-936-1600
Is Sole Proprietor?:No
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL28552255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer