Healthcare Provider Details

I. General information

NPI: 1508352964
Provider Name (Legal Business Name): REBECCA LYNN GOLLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2018
Last Update Date: 07/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 SCHOOL ST
WELLSVILLE NY
14895-1631
US

IV. Provider business mailing address

6728 HORN HILL RD
ELLICOTTVILLE NY
14731-9625
US

V. Phone/Fax

Practice location:
  • Phone: 716-801-1428
  • Fax:
Mailing address:
  • Phone: 716-801-1428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number009764-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: