Provider Demographics
NPI:1295139392
Name:SMITH, REBECCA (LMT, LLCC)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMT, LLCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 FENIMORE ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-5368
Mailing Address - Country:US
Mailing Address - Phone:917-865-1643
Mailing Address - Fax:
Practice Address - Street 1:123 FENIMORE ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-5368
Practice Address - Country:US
Practice Address - Phone:917-865-1643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024689225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist