Provider Demographics
NPI:1801251244
Name:CUSHING, REBECCA LYNN
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:LYNN
Last Name:CUSHING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LYNN
Other - Last Name:AMANDUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5909 W. STATE ST.
Mailing Address - Street 2:PHYSICAL THERAPY 180
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703
Mailing Address - Country:US
Mailing Address - Phone:208-343-7700
Mailing Address - Fax:208-331-2591
Practice Address - Street 1:5909 W. STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703
Practice Address - Country:US
Practice Address - Phone:208-343-7700
Practice Address - Fax:208-331-2591
Is Sole Proprietor?:No
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MASG2257225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDMASG2257OtherLICENSE