Provider Demographics
NPI:1386998466
Name:LARSEN-DECKER, REBECCA ROSE (LMT)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:ROSE
Last Name:LARSEN-DECKER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ROSE
Other - Last Name:LARSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:PO BOX 248
Mailing Address - Street 2:
Mailing Address - City:ROSENDALE
Mailing Address - State:NY
Mailing Address - Zip Code:12472-0248
Mailing Address - Country:US
Mailing Address - Phone:845-594-2160
Mailing Address - Fax:
Practice Address - Street 1:449 RTE. 213 MAIN ST.
Practice Address - Street 2:
Practice Address - City:ROSENDALE
Practice Address - State:NY
Practice Address - Zip Code:12472
Practice Address - Country:US
Practice Address - Phone:845-594-2160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016791225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist