Provider Demographics
NPI:1578394169
Name:GILLEY, REBECCA BLOOMER
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:BLOOMER
Last Name:GILLEY
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 1:105 BIRDWATCH LN
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-8172
Mailing Address - Country:US
Mailing Address - Phone:337-315-0014
Mailing Address - Fax:
Practice Address - Street 1:5522 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:
Practice Address - City:YOUNGSVILLE
Practice Address - State:LA
Practice Address - Zip Code:70592-5279
Practice Address - Country:US
Practice Address - Phone:337-703-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.Z12394225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist