Provider Demographics
NPI:1407053077
Name:MERMOD, REBECCA JUDY (COTA)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:JUDY
Last Name:MERMOD
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 FORT GATE RD
Mailing Address - Street 2:
Mailing Address - City:NORDLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98358-9516
Mailing Address - Country:US
Mailing Address - Phone:360-379-1881
Mailing Address - Fax:
Practice Address - Street 1:1116 E LAURIDSEN BLVD
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6640
Practice Address - Country:US
Practice Address - Phone:360-452-9206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC00000662224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant