Provider Demographics
NPI:1417074329
Name:RANDOLPH, REBECCA HARPER (PT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:HARPER
Last Name:RANDOLPH
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 1:2855 ADAM AVE
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:IL
Mailing Address - Zip Code:60538-5107
Mailing Address - Country:US
Mailing Address - Phone:630-844-0843
Mailing Address - Fax:630-859-3901
Practice Address - Street 1:2855 ADAM AVE
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:IL
Practice Address - Zip Code:60538-5107
Practice Address - Country:US
Practice Address - Phone:630-844-0843
Practice Address - Fax:630-859-3901
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist