Provider Demographics
NPI:1700221819
Name:MAGGIO, REBECCA PRINCE (LOTR)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:PRINCE
Last Name:MAGGIO
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4719 BRUCE ST
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2607
Mailing Address - Country:US
Mailing Address - Phone:318-372-7035
Mailing Address - Fax:
Practice Address - Street 1:2522 E 70TH ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-4002
Practice Address - Country:US
Practice Address - Phone:318-798-5918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.200610225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist