Provider Demographics
NPI:1164749081
Name:TYSON, REBECCA PETERS (MA CCC/SLP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:PETERS
Last Name:TYSON
Suffix:
Gender:F
Credentials:MA CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 ELF WAY
Mailing Address - Street 2:
Mailing Address - City:CLEAR BROOK
Mailing Address - State:VA
Mailing Address - Zip Code:22624-1489
Mailing Address - Country:US
Mailing Address - Phone:304-886-1826
Mailing Address - Fax:
Practice Address - Street 1:132 ELF WAY
Practice Address - Street 2:
Practice Address - City:CLEAR BROOK
Practice Address - State:VA
Practice Address - Zip Code:22624-1489
Practice Address - Country:US
Practice Address - Phone:304-886-1826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-02
Last Update Date:2010-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202004757235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist