Provider Demographics
NPI:1235774894
Name:NEILL, REBECCA LOUISE (BS, QDDP, MHRT/C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LOUISE
Last Name:NEILL
Suffix:
Gender:F
Credentials:BS, QDDP, MHRT/C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 HOFSTADTER RD STE 125
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-3066
Mailing Address - Country:US
Mailing Address - Phone:757-969-8669
Mailing Address - Fax:757-401-4527
Practice Address - Street 1:630 HOFSTADTER RD STE 125
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-3066
Practice Address - Country:US
Practice Address - Phone:757-969-8669
Practice Address - Fax:757-401-4527
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0832730383Medicaid