Provider Demographics
NPI:1639842214
Name:KOOGLER, REBECCA TAYLOR
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:TAYLOR
Last Name:KOOGLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:KOOGLER
Other - Last Name:BAUCHER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:125 BLUE HERON DR STE B
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77316-3183
Mailing Address - Country:US
Mailing Address - Phone:936-582-0404
Mailing Address - Fax:
Practice Address - Street 1:125 BLUE HERON DR STE B
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77316-3183
Practice Address - Country:US
Practice Address - Phone:936-582-0404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14668111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor