Provider Demographics
NPI:1184789828
Name:MAIR, REBECCA ANNE (PHD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:ANNE
Last Name:MAIR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 WHITTIER RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1114
Mailing Address - Country:US
Mailing Address - Phone:313-310-9843
Mailing Address - Fax:313-884-9758
Practice Address - Street 1:15450 E JEFFERSON AVE STE 140
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE PARK
Practice Address - State:MI
Practice Address - Zip Code:48230-2033
Practice Address - Country:US
Practice Address - Phone:313-821-0098
Practice Address - Fax:313-884-9758
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008126171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0894458Medicare ID - Type Unspecified
MIR83849Medicare UPIN