Provider Demographics
NPI:1750862777
Name:GILLENTINE, REBECCA JANE (PTA)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:JANE
Last Name:GILLENTINE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 SLOVAK RD
Mailing Address - Street 2:
Mailing Address - City:ENNIS
Mailing Address - State:TX
Mailing Address - Zip Code:75119-7275
Mailing Address - Country:US
Mailing Address - Phone:469-438-6492
Mailing Address - Fax:
Practice Address - Street 1:316 SLOVAK RD
Practice Address - Street 2:
Practice Address - City:ENNIS
Practice Address - State:TX
Practice Address - Zip Code:75119-7275
Practice Address - Country:US
Practice Address - Phone:469-438-6492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2135789225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant