Basic Information
| Provider Information | |||||||||
| NPI: | 1376020834 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | RACHEL | ||||||||
| MiddleName: | RUTHANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 E UNIVERSITY BLVD APT 11 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329017173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3474810020 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 453 KING ST | ||||||||
| Address2: | |||||||||
| City: | COCOA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329227621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216335511 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2018 | ||||||||
| LastUpdateDate: | 07/26/2018 | ||||||||
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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 | 106S00000X | RBT-17-43077 | FL | Y |
ID Information
| ID | Type | State | Issuer | Description | 021403200 | 05 | FL | MEDICAID |