Provider Demographics
NPI:1700217825
Name:REBULLOSA, BEATRICE ANGELINA (LMT)
Entity Type:Individual
Prefix:
First Name:BEATRICE
Middle Name:ANGELINA
Last Name:REBULLOSA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8550 SW ASH MEADOWS RD APT 425
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-4027
Mailing Address - Country:US
Mailing Address - Phone:503-758-9580
Mailing Address - Fax:
Practice Address - Street 1:8550 SW ASH MEADOWS RD APT 425
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-4027
Practice Address - Country:US
Practice Address - Phone:503-758-9580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-30
Last Update Date:2013-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20142225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist