Provider Demographics
NPI:1326547647
Name:KELLER, REBECCA ANN (MPT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:KELLER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ANN
Other - Last Name:RING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:W384N8292 HIGHLANDER DR
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-9654
Mailing Address - Country:US
Mailing Address - Phone:262-751-3090
Mailing Address - Fax:
Practice Address - Street 1:1185 CORPORATE CENTER DR STE 250
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4888
Practice Address - Country:US
Practice Address - Phone:262-928-8847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-02
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10209-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist