Provider Demographics
NPI:1841705035
Name:DONALDSON, REBECCA RENAE
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:RENAE
Last Name:DONALDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 W 22ND ST
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-1229
Mailing Address - Country:US
Mailing Address - Phone:909-344-7991
Mailing Address - Fax:
Practice Address - Street 1:1490 N CLAREMONT BLVD
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-3519
Practice Address - Country:US
Practice Address - Phone:909-344-7991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-09
Last Update Date:2017-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11644235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty