Provider Demographics
NPI:1619165784
Name:RUPERT, RENEE' WENNELL (PTA)
Entity Type:Individual
Prefix:MS
First Name:RENEE'
Middle Name:WENNELL
Last Name:RUPERT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:RENEE'
Other - Middle Name:MAE
Other - Last Name:WENNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:132 HOWLAND RD
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02347-2214
Mailing Address - Country:US
Mailing Address - Phone:508-946-1414
Mailing Address - Fax:
Practice Address - Street 1:31 W GROVE ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02346-1806
Practice Address - Country:US
Practice Address - Phone:508-947-5195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-14
Last Update Date:2007-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1136225200000X
FLPTA000517225200000X
NY000706-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant