Provider Demographics
NPI:1295782951
Name:MOTLEY, REBECCA KATHLEENE (MD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:KATHLEENE
Last Name:MOTLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:20245 W 12 MILE RD STE 120
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-6406
Mailing Address - Country:US
Mailing Address - Phone:248-552-1327
Mailing Address - Fax:248-552-1183
Practice Address - Street 1:20245 W 12 MILE RD STE 120
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-6406
Practice Address - Country:US
Practice Address - Phone:248-552-1327
Practice Address - Fax:248-552-1183
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301407599208D00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301407599OtherSTATE LICENSE
MI1102-70-0582OtherBCBS
MI4715780-10Medicaid
MIBM1416571OtherDEA
MI0N98170Medicare ID - Type Unspecified