Provider Demographics
NPI:1053761171
Name:ROESSLER, REBEKAH
Entity type:Individual
Prefix:
First Name:REBEKAH
Middle Name:
Last Name:ROESSLER
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 1:303 KIMBERLY LN
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-4010
Mailing Address - Country:US
Mailing Address - Phone:636-248-9103
Mailing Address - Fax:
Practice Address - Street 1:2687 AKINS BLVD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458
Practice Address - Country:US
Practice Address - Phone:912-478-5436
Practice Address - Fax:912-478-1892
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-20
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
20000285312255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer