Provider Demographics
NPI:1558593194
Name:RETHERFORD, LUKE JARED (OTR/L)
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:JARED
Last Name:RETHERFORD
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 AQUA VISTA LN APT 111
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-1262
Mailing Address - Country:US
Mailing Address - Phone:256-436-3746
Mailing Address - Fax:
Practice Address - Street 1:1690 US HIGHWAY 1 S
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-4192
Practice Address - Country:US
Practice Address - Phone:904-810-2101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-16
Last Update Date:2009-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13677225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation