MEDICARE: REBECCA JOHN OTR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist	119586	TX

General Provider Information

NPI Number	:	1952945404
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA JOHN OTR

Provider Business Mailing Address
First Line	:	305 NE LOOP 820
Second Line	:	BUSINESS TOWER 1, SUITE 200
City	:	HURST
State	:	TX
Zip	:	76053-7202
Country	:	US
Telephone Number	:	817-292-8787
Fax Number	:	817-789-6849

Provider Business Practice Location Address
First Line	:	3930 ACCENT DR APT 2121
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75287-7716
Country	:	US
Telephone Number	:	940-577-2577
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2019
Last Update Date	:	03/30/2020

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