Provider Demographics
NPI:1871822536
Name:BETHEL, REBECCA A (PT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:BETHEL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 MARKET CENTER BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8407
Mailing Address - Country:US
Mailing Address - Phone:636-244-8248
Mailing Address - Fax:
Practice Address - Street 1:1630 MARKET CENTER BLVD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-8407
Practice Address - Country:US
Practice Address - Phone:362-638-2486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-09
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO111962174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO151100019Medicare PIN
MO150900020Medicare PIN