Provider Demographics
NPI:1235799099
Name:FLEMING, REBECCA GIBBS
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:GIBBS
Last Name:FLEMING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 MANOR PL
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-7132
Mailing Address - Country:US
Mailing Address - Phone:317-502-1816
Mailing Address - Fax:
Practice Address - Street 1:2645 W RANDOL MILL RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-4228
Practice Address - Country:US
Practice Address - Phone:817-277-6789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113273235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113273Medicaid