Provider Demographics
NPI:1700150612
Name:PREVOZNIK, REBECCA (PTA, MHA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:PREVOZNIK
Suffix:
Gender:F
Credentials:PTA, MHA
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:SUE
Other - Last Name:SOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:264 N WHITEOAK ST
Mailing Address - Street 2:
Mailing Address - City:KUTZTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19530-1426
Mailing Address - Country:US
Mailing Address - Phone:610-683-0737
Mailing Address - Fax:
Practice Address - Street 1:264 N WHITEOAK ST
Practice Address - Street 2:
Practice Address - City:KUTZTOWN
Practice Address - State:PA
Practice Address - Zip Code:19530-1426
Practice Address - Country:US
Practice Address - Phone:610-683-0737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-24
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI000875225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant