Healthcare Provider Details

I. General information

NPI: 1871822536
Provider Name (Legal Business Name): REBECCA A BETHEL P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2009
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 MARKET CENTER BLVD
O FALLON MO
63368-8407
US

IV. Provider business mailing address

1630 MARKET CENTER BLVD STE 202
O FALLON MO
63368-8407
US

V. Phone/Fax

Practice location:
  • Phone: 362-638-2486
  • Fax:
Mailing address:
  • Phone: 636-244-8248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number111962
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: