Provider Demographics
NPI:1154898302
Name:MOHR, REBECCA LYNN (LPT)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:MOHR
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LYNN
Other - Last Name:OUTLAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPT
Mailing Address - Street 1:955 W CENTER ST STE 12A
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-7327
Mailing Address - Country:US
Mailing Address - Phone:209-239-9600
Mailing Address - Fax:209-239-2244
Practice Address - Street 1:955 W CENTER ST STE 12A
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-7327
Practice Address - Country:US
Practice Address - Phone:209-239-9600
Practice Address - Fax:209-239-2244
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26531167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician