Provider Demographics
NPI:1427598770
Name:REBECCA, GABRIELLE KATHRYN (ATC/LAT)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:KATHRYN
Last Name:REBECCA
Suffix:
Gender:F
Credentials:ATC/LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 W FAIRMONT ST
Mailing Address - Street 2:APT 207
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-6300
Mailing Address - Country:US
Mailing Address - Phone:254-722-1370
Mailing Address - Fax:
Practice Address - Street 1:2201 W GAY AVE
Practice Address - Street 2:
Practice Address - City:GLADEWATER
Practice Address - State:TX
Practice Address - Zip Code:75647-4357
Practice Address - Country:US
Practice Address - Phone:903-845-5591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT46472255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer