Provider Demographics
NPI:1487960365
Name:BECKER, JUSTINA ROSE (DPT)
Entity type:Individual
Prefix:MRS
First Name:JUSTINA
Middle Name:ROSE
Last Name:BECKER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JUSTINA
Other - Middle Name:ROSE
Other - Last Name:BAUER THORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1888
Mailing Address - Street 2:
Mailing Address - City:LA PINE
Mailing Address - State:OR
Mailing Address - Zip Code:97739-1888
Mailing Address - Country:US
Mailing Address - Phone:541-536-6122
Mailing Address - Fax:541-536-6123
Practice Address - Street 1:51681 HUNTINGTON RD
Practice Address - Street 2:
Practice Address - City:LA PINE
Practice Address - State:OR
Practice Address - Zip Code:97739-9626
Practice Address - Country:US
Practice Address - Phone:541-536-6122
Practice Address - Fax:541-536-6123
Is Sole Proprietor?:No
Enumeration Date:2010-08-30
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6265225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500682503Medicaid