Provider Demographics
NPI:1427481829
Name:STREET, REBECCA (DPT)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:STREET
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 INDUSTRIAL AVE
Mailing Address - Street 2:SUITE 190
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-4448
Mailing Address - Country:US
Mailing Address - Phone:802-860-4360
Mailing Address - Fax:
Practice Address - Street 1:120 GRAHAM WAY STE 110
Practice Address - Street 2:
Practice Address - City:SHELBURNE
Practice Address - State:VT
Practice Address - Zip Code:05482-7217
Practice Address - Country:US
Practice Address - Phone:802-985-9360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040.0094841225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1022197Medicaid