Provider Demographics
NPI:1871627695
Name:RETTIG, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:RETTIG
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 1:199 RAIBLE DR
Mailing Address - Street 2:
Mailing Address - City:DUNCANSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16635-6917
Mailing Address - Country:US
Mailing Address - Phone:814-696-0983
Mailing Address - Fax:
Practice Address - Street 1:111 MARKET ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15901-1608
Practice Address - Country:US
Practice Address - Phone:814-539-1919
Practice Address - Fax:814-539-1308
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL003577L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1016178770001Medicaid