Provider Demographics
NPI:1366153801
Name:LANGLEY, REBECKA
Entity type:Individual
Prefix:
First Name:REBECKA
Middle Name:
Last Name:LANGLEY
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 1:1846 SE HANKEL ST
Mailing Address - Street 2:DALLAS, OREGON 97338
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338
Mailing Address - Country:US
Mailing Address - Phone:503-799-8650
Mailing Address - Fax:
Practice Address - Street 1:1846 SE HANKEL ST
Practice Address - Street 2:DALLAS, OREGON 97338
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-9733
Practice Address - Country:US
Practice Address - Phone:503-799-8650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR174200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174200000XOther Service ProvidersMeals