Healthcare Provider Details

I. General information

NPI: 1952661266
Provider Name (Legal Business Name): REBECCA MCBRIDE OT/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: REBECCA LUSK OT/L

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 01/27/2020
Certification Date: 01/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 BURLEYSON RD
DALTON GA
30720-3019
US

IV. Provider business mailing address

1201 BURLEYSON RD
DALTON GA
30720-3019
US

V. Phone/Fax

Practice location:
  • Phone: 706-226-8900
  • Fax: 706-226-8905
Mailing address:
  • Phone: 706-226-8900
  • Fax: 706-226-8905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT0000000933
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT003134
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: