Provider Demographics
NPI:1003986506
Name:ANDERSON, REBECCA (PT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 WINNS CIR
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22602-6940
Mailing Address - Country:US
Mailing Address - Phone:540-722-9591
Mailing Address - Fax:
Practice Address - Street 1:130 MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-3322
Practice Address - Country:US
Practice Address - Phone:540-667-7076
Practice Address - Fax:540-667-5773
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305002388174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004944Medicaid
VA3810004945Medicaid
VA650000259Medicare PIN