Provider Demographics
NPI:1932873627
Name:WIXOM, REBEKAH JENE I
Entity Type:Individual
Prefix:MS
First Name:REBEKAH
Middle Name:JENE
Last Name:WIXOM
Suffix:I
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 1:1547 WADE HAMPTON BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29609-5047
Mailing Address - Country:US
Mailing Address - Phone:864-659-0604
Mailing Address - Fax:
Practice Address - Street 1:1547 WADE HAMPTON BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609-5047
Practice Address - Country:US
Practice Address - Phone:864-659-0604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC74882355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Single Specialty