Provider Demographics
NPI:1235488677
Name:BAUMGARDNER, REBECCA SUE (MED, OTR/L)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUE
Last Name:BAUMGARDNER
Suffix:
Gender:F
Credentials:MED, OTR/L
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:SUE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, OTR/L
Mailing Address - Street 1:2715 LILAC ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3526
Mailing Address - Country:US
Mailing Address - Phone:360-575-7008
Mailing Address - Fax:
Practice Address - Street 1:2715 LILAC ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3526
Practice Address - Country:US
Practice Address - Phone:360-575-7008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5474225X00000X
WAOT00001967225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist