Provider Demographics
NPI:1659884823
Name:PORSIA, REBECCA RAE (LMT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:RAE
Last Name:PORSIA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:RAE
Other - Last Name:DOUGHTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-4125
Mailing Address - Country:US
Mailing Address - Phone:518-203-8939
Mailing Address - Fax:
Practice Address - Street 1:211 OLD LOUDON RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2938
Practice Address - Country:US
Practice Address - Phone:518-203-8939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-10
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024170225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty