Provider Demographics
NPI:1528356573
Name:WENTWORTH, REBECCA LYNNE
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNNE
Last Name:WENTWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5443 OLIVER CT NW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-5822
Mailing Address - Country:US
Mailing Address - Phone:770-364-1857
Mailing Address - Fax:
Practice Address - Street 1:7050 JIMMY CARTER BLVD
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-3257
Practice Address - Country:US
Practice Address - Phone:770-364-1857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-12
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GABR009324225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist