Provider Demographics
NPI:1407539927
Name:GARDOM, REBECCA LYNN (MATVI, CLVT, COMS)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:GARDOM
Suffix:
Gender:F
Credentials:MATVI, CLVT, COMS
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4505 S PAGOSA CIR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80015-1920
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4505 S PAGOSA CIR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80015-1920
Practice Address - Country:US
Practice Address - Phone:928-245-3164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ22576225CX0006X
AZ57812255R0406X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255R0406XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistRehabilitation, Blind
No225CX0006XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorOrientation and Mobility Training Provider