Healthcare Provider Details

I. General information

NPI: 1063385854
Provider Name (Legal Business Name): REBECCA KNOCKEMUS RDLD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 8TH AVE STE 200
FORT WORTH TX
76104-2500
US

IV. Provider business mailing address

750 8TH AVE STE 200
FORT WORTH TX
76104-2500
US

V. Phone/Fax

Practice location:
  • Phone: 682-885-2170
  • Fax: 817-335-8277
Mailing address:
  • Phone: 817-347-4692
  • Fax: 817-335-8277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT90721
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: