Healthcare Provider Details

I. General information

NPI: 1881505030
Provider Name (Legal Business Name): REBECCA THEADORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 CENTURY HILL DR STE 207
LATHAM NY
12110-2128
US

IV. Provider business mailing address

26 CENTURY HILL DR STE 207
LATHAM NY
12110-2128
US

V. Phone/Fax

Practice location:
  • Phone: 838-232-5481
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: