Provider Demographics
NPI:1497734503
Name:PRIVITT, REBECCA L (PT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:PRIVITT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:L
Other - Last Name:PUCKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:8561 W FISHER AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89149-4057
Mailing Address - Country:US
Mailing Address - Phone:702-545-0265
Mailing Address - Fax:928-771-9519
Practice Address - Street 1:4765 S DURANGO DR
Practice Address - Street 2:SUITE #106
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-8145
Practice Address - Country:US
Practice Address - Phone:702-898-7633
Practice Address - Fax:927-881-9519
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2039261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ783292Medicaid
AZ76277Medicare ID - Type Unspecified
AZ783292Medicaid