Provider Demographics
NPI:1619566163
Name:THREATT, REBECCA (LMT)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:
Last Name:THREATT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 HERITAGE OAK DR
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77320-3081
Mailing Address - Country:US
Mailing Address - Phone:713-591-3548
Mailing Address - Fax:
Practice Address - Street 1:1215 SAM HOUSTON AVE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340-4637
Practice Address - Country:US
Practice Address - Phone:713-591-3548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT048798225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXMT048798OtherTEXAS DEPARTMENT OF LICENSING AND REGULATION