Provider Demographics
NPI:1497340863
Name:CAST-REBOLLO, LORIE (DACM, MSAOM, BS, LMT)
Entity Type:Individual
Prefix:DR
First Name:LORIE
Middle Name:
Last Name:CAST-REBOLLO
Suffix:
Gender:F
Credentials:DACM, MSAOM, BS, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7703 INGRAM RD APT 2707
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-1759
Mailing Address - Country:US
Mailing Address - Phone:816-799-1307
Mailing Address - Fax:
Practice Address - Street 1:7703 INGRAM RD APT 2707
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-1759
Practice Address - Country:US
Practice Address - Phone:816-799-1307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-07
Last Update Date:2021-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003016478225700000X
TX121987225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist