Provider Demographics
NPI:1740895788
Name:NIAMTU, REBECCA (CMT 74122)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:NIAMTU
Suffix:
Gender:F
Credentials:CMT 74122
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:364 S CLOVERDALE AVE # B1
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-3478
Mailing Address - Country:US
Mailing Address - Phone:910-616-6830
Mailing Address - Fax:
Practice Address - Street 1:364 S CLOVERDALE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-3478
Practice Address - Country:US
Practice Address - Phone:910-616-6830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74122208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation