Provider Demographics
NPI:1710330162
Name:WARD, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:WARD
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 1:176 ATLANTA ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-2110
Mailing Address - Country:US
Mailing Address - Phone:678-683-1901
Mailing Address - Fax:
Practice Address - Street 1:176 ATLANTA ST
Practice Address - Street 2:SUITE B
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-2110
Practice Address - Country:US
Practice Address - Phone:678-683-1901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT005304225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist