Basic Information
| Provider Information | |||||||||
| NPI: | 1144770397 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUILLEN | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | SOPHIA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ATC, LAT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HERR | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | SOPHIA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ATC, LAT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2901 BUSCH LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336141860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139367979 | ||||||||
| FaxNumber: | 8139361600 | ||||||||
| Practice Location | |||||||||
| Address1: | 2901 BUSCH LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336141860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139367979 | ||||||||
| FaxNumber: | 8139361600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2016 | ||||||||
| LastUpdateDate: | 10/12/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AL2855 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.