Provider Demographics
NPI:1366920803
Name:BOOTH, REBECCA (DPT)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BOOTH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:804 TABITHA LN
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:64034-8659
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40 1ST ST SE
Practice Address - Street 2:
Practice Address - City:WAUKON
Practice Address - State:IA
Practice Address - Zip Code:52172-2022
Practice Address - Country:US
Practice Address - Phone:563-568-3411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-06
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018028386225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist