Healthcare Provider Details

I. General information

NPI: 1801626452
Provider Name (Legal Business Name): HALEY REBECCA PAULK PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2024
Last Update Date: 08/07/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 S FERDON BLVD
CRESTVIEW FL
32536-5235
US

IV. Provider business mailing address

91 SHARON CT
DEFUNIAK SPRINGS FL
32433-3523
US

V. Phone/Fax

Practice location:
  • Phone: 850-863-2153
  • Fax:
Mailing address:
  • Phone: 850-333-6784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT40561
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: