Provider Demographics
NPI:1083912935
Name:ELLIOTT, REBECCA ALLISON (PT, DPT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ALLISON
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:558 MEDALIST WAY SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-4181
Mailing Address - Country:US
Mailing Address - Phone:770-483-1476
Mailing Address - Fax:
Practice Address - Street 1:5470 MERIDIAN MARKS RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1624
Practice Address - Country:US
Practice Address - Phone:404-256-5131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010130225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist