=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114381829
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBECCA STRAUB ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2016
-----------------------------------------------------
Last Update Date | 05/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 FAIRVIEW AVE
-----------------------------------------------------
City | ANDOVER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14806-9310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-307-7995
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 UPPER COLLEGE DR
-----------------------------------------------------
City | ALFRED
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14802-1153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-587-4388
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 003523
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------