Provider Demographics
NPI:1972952182
Name:BRANCHEAU, REBECCA (LMT)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BRANCHEAU
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 E MILHAM AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-3096
Mailing Address - Country:US
Mailing Address - Phone:269-220-5033
Mailing Address - Fax:
Practice Address - Street 1:1125 E MILHAM AVE
Practice Address - Street 2:SUITE C
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-3096
Practice Address - Country:US
Practice Address - Phone:269-220-5033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501004536174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist