Provider Demographics
NPI:1972897049
Name:GRAHAM, REBECCA MARIE (PTA)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:MARIE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:MARIE
Other - Last Name:LINKHART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:1126 DODGE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-3530
Mailing Address - Country:US
Mailing Address - Phone:260-413-0974
Mailing Address - Fax:
Practice Address - Street 1:1126 DODGE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-3530
Practice Address - Country:US
Practice Address - Phone:260-413-0974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-06
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002651A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant