Provider Demographics
NPI:1164975397
Name:FRY, REBECCA GAIL
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:GAIL
Last Name:FRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:GAIL
Other - Last Name:MORFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:4560 SE INTERNATIONAL WAY
Mailing Address - Street 2:ATE 100
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-4628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4560 SE INTERNATIONAL WAY
Practice Address - Street 2:ATE 100
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-4628
Practice Address - Country:US
Practice Address - Phone:208-515-9471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-23
Last Update Date:2016-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTA-1160224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant