Provider Demographics
NPI:1689257578
Name:MOORE, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:MOORE
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 1:25749 S RED STABLE LN
Mailing Address - Street 2:
Mailing Address - City:CHANNAHON
Mailing Address - State:IL
Mailing Address - Zip Code:60410-8611
Mailing Address - Country:US
Mailing Address - Phone:630-777-0448
Mailing Address - Fax:
Practice Address - Street 1:505 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-3858
Practice Address - Country:US
Practice Address - Phone:815-434-1130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant