Healthcare Provider Details

I. General information

NPI: 1750780334
Provider Name (Legal Business Name): REBEKAH REICHARD ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2014
Last Update Date: 08/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 UNION ST
VALPARAISO IN
46383-4529
US

IV. Provider business mailing address

1009 UNION ST
VALPARAISO IN
46383-4529
US

V. Phone/Fax

Practice location:
  • Phone: 219-464-5236
  • Fax: 219-464-6897
Mailing address:
  • Phone: 219-464-5236
  • Fax: 219-464-6897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36001836A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: