Provider Demographics
NPI:1699524538
Name:WANGBERG, REBECCA MARIE
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:MARIE
Last Name:WANGBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 151
Mailing Address - Street 2:
Mailing Address - City:COLMAN
Mailing Address - State:SD
Mailing Address - Zip Code:57017-0151
Mailing Address - Country:US
Mailing Address - Phone:605-929-8623
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 151
Practice Address - Street 2:
Practice Address - City:COLMAN
Practice Address - State:SD
Practice Address - Zip Code:57017-0151
Practice Address - Country:US
Practice Address - Phone:605-929-8623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-14
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1236225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist