Provider Demographics
NPI:1982146759
Name:SMITH, REBECCA LYNN (COTA/L)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:WESTERNPORT
Mailing Address - State:MD
Mailing Address - Zip Code:21562-1121
Mailing Address - Country:US
Mailing Address - Phone:301-876-8976
Mailing Address - Fax:
Practice Address - Street 1:1 KAYLOR CIR
Practice Address - Street 2:
Practice Address - City:FROSTBURG
Practice Address - State:MD
Practice Address - Zip Code:21532-2009
Practice Address - Country:US
Practice Address - Phone:301-689-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-10
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA02418224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant