Healthcare Provider Details

I. General information

NPI: 1760969752
Provider Name (Legal Business Name): REBECCA ANN BANATAO DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: REBECCA ANN BOURESSA

II. Dates (important events)

Enumeration Date: 07/23/2018
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14333 SEAGATE DR
SAN LEANDRO CA
94577-6412
US

IV. Provider business mailing address

380 DIABLO RD STE 201
DANVILLE CA
94526-3410
US

V. Phone/Fax

Practice location:
  • Phone: 920-268-2091
  • Fax:
Mailing address:
  • Phone: 925-552-5787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number295043
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: