Provider Demographics
NPI:1063960045
Name:CARSON, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:CARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3693 OAKDALE CIR APT 201
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-8097
Mailing Address - Country:US
Mailing Address - Phone:586-441-1170
Mailing Address - Fax:
Practice Address - Street 1:4000 CENTRAL FLORIDA BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32816-7801
Practice Address - Country:US
Practice Address - Phone:586-441-1170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-19
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL57902255A2300X
MIC 625 734 385 111390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer