Provider Demographics
NPI:1376633198
Name:STREET, REBECCA KAY (PT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:KAY
Last Name:STREET
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 DRY HOLLOW RD STE 1
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3167
Mailing Address - Country:US
Mailing Address - Phone:541-296-3368
Mailing Address - Fax:541-296-7866
Practice Address - Street 1:1210 DRY HOLLOW RD STE 1
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3167
Practice Address - Country:US
Practice Address - Phone:541-296-3368
Practice Address - Fax:541-296-7866
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1879225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR212502263357OtherLIFEWISE PROVIDER #
OR093559OtherOMAP PROVIDER #
OR50324OtherCCHP PROVIDER NUMBER
OR212502263357OtherLIFEWISE PROVIDER #