Provider Demographics
NPI:1033417597
Name:WISE, REBECCA A (OTR/L)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:WISE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 N BUCHANAN ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22203-1426
Mailing Address - Country:US
Mailing Address - Phone:703-303-6421
Mailing Address - Fax:
Practice Address - Street 1:6506 LOISDALE RD
Practice Address - Street 2:SUITE 302
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-1824
Practice Address - Country:US
Practice Address - Phone:703-924-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-08
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119005300225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist