Provider Demographics
NPI:1497313340
Name:MOEHLENBROCK, REBECCA LYNNE (PTA)
Entity Type:Individual
Prefix:MISS
First Name:REBECCA
Middle Name:LYNNE
Last Name:MOEHLENBROCK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 WARD LN
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-2918
Mailing Address - Country:US
Mailing Address - Phone:314-504-0696
Mailing Address - Fax:
Practice Address - Street 1:711 LUCAS DR.
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751
Practice Address - Country:US
Practice Address - Phone:903-675-8538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2108688225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant