Basic Information
| Provider Information | |||||||||
| NPI: | 1740308410 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE KEYSER | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 E ROUTE 66 | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GLENDORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917404659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268592089 | ||||||||
| FaxNumber: | 6268596537 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 E ROUTE 66 | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GLENDORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917404659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268592089 | ||||||||
| FaxNumber: | 6268596537 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 05/10/2013 | ||||||||
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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 | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
ID Information
| ID | Type | State | Issuer | Description | ICAN692 | 01 | CA | LACDMH STAFF CODE | OTHER |