Provider Demographics
NPI:1477810042
Name:WAGNER, REBEKAH F (MPT)
Entity type:Individual
Prefix:
First Name:REBEKAH
Middle Name:F
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5510 EAST STATE STREET
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108
Mailing Address - Country:US
Mailing Address - Phone:815-395-4505
Mailing Address - Fax:815-395-4591
Practice Address - Street 1:3100 SYCAMORE RD
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-9621
Practice Address - Country:US
Practice Address - Phone:815-753-1383
Practice Address - Fax:815-753-3299
Is Sole Proprietor?:No
Enumeration Date:2012-04-19
Last Update Date:2017-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.016673225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist