Provider Demographics
NPI:1275614042
Name:KLOSE, BECKY BUBECK (ATC)
Entity Type:Individual
Prefix:
First Name:BECKY
Middle Name:BUBECK
Last Name:KLOSE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:BECKY
Other - Middle Name:ANN
Other - Last Name:BUBECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:2903 UNRUH AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149-2527
Mailing Address - Country:US
Mailing Address - Phone:215-332-1953
Mailing Address - Fax:215-717-6238
Practice Address - Street 1:2903 UNRUH AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-2527
Practice Address - Country:US
Practice Address - Phone:215-332-1953
Practice Address - Fax:215-717-6238
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0034922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA991160OtherNATIONAL ATC
PART003492OtherLICENSED ATHLETIC TRAINER