Provider Demographics
NPI:1457590846
Name:WARDLAW, REBECCA LYN (ATC, MA, LAT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYN
Last Name:WARDLAW
Suffix:
Gender:F
Credentials:ATC, MA, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13312 JAYNES PLZ APT 305
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-1059
Mailing Address - Country:US
Mailing Address - Phone:402-499-5260
Mailing Address - Fax:
Practice Address - Street 1:12809 W DODGE RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-2155
Practice Address - Country:US
Practice Address - Phone:402-206-1945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-09
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE4412255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer