Provider Demographics
NPI:1366851503
Name:SANDERS, REBECCA ROSE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:ROSE
Last Name:SANDERS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12317 RENATA DR
Mailing Address - Street 2:
Mailing Address - City:BLACK HAWK
Mailing Address - State:SD
Mailing Address - Zip Code:57718-9373
Mailing Address - Country:US
Mailing Address - Phone:605-920-0659
Mailing Address - Fax:
Practice Address - Street 1:353 FAIRMONT BLVD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7375
Practice Address - Country:US
Practice Address - Phone:605-755-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0265225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant