Healthcare Provider Details

I. General information

NPI: 1649487208
Provider Name (Legal Business Name): REBECCA MARIE HYDRICK OTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 N 3RD ST STE 200
PHOENIX AZ
85004-3932
US

IV. Provider business mailing address

3868 E ESPLANADE AVE
GILBERT AZ
85297-5405
US

V. Phone/Fax

Practice location:
  • Phone: 602-528-3450
  • Fax:
Mailing address:
  • Phone: 480-988-3820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2473
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: