Basic Information
| Provider Information | |||||||||
| NPI: | 1487960365 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BECKER | ||||||||
| FirstName: | JUSTINA | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BAUER THORN | ||||||||
| OtherFirstName: | JUSTINA | ||||||||
| OtherMiddleName: | ROSE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1888 | ||||||||
| Address2: | |||||||||
| City: | LA PINE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977391888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415366122 | ||||||||
| FaxNumber: | 5415366123 | ||||||||
| Practice Location | |||||||||
| Address1: | 51681 HUNTINGTON RD | ||||||||
| Address2: | |||||||||
| City: | LA PINE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977399626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415366122 | ||||||||
| FaxNumber: | 5415366123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2010 | ||||||||
| LastUpdateDate: | 11/03/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 6265 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 500682503 | 05 | OR | MEDICAID |