Healthcare Provider Details

I. General information

NPI: 1295845519
Provider Name (Legal Business Name): REBECCA MCQUEEN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

701 DORSET ST APT 5
SOUTH BURLINGTON VT
05403-7150
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-2450
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number041-0000332
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: