Provider Demographics
NPI:1821042524
Name:FAULK, REBECCA C (OTR/L)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:C
Last Name:FAULK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 BELLEVIEW ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-1807
Mailing Address - Country:US
Mailing Address - Phone:803-255-0174
Mailing Address - Fax:
Practice Address - Street 1:1003 BELLEVIEW ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-1807
Practice Address - Country:US
Practice Address - Phone:803-255-0174
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2543174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1222Medicaid