Provider Demographics
NPI:1487815767
Name:GRIDER, REBECCA LOUISE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:LOUISE
Last Name:GRIDER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 CHAMA ST NE STE 10
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-3595
Mailing Address - Country:US
Mailing Address - Phone:505-888-9663
Mailing Address - Fax:
Practice Address - Street 1:540 CHAMA ST NE STE 10
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-3595
Practice Address - Country:US
Practice Address - Phone:505-888-9663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5960172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist