Provider Demographics
NPI:1558835959
Name:KELLY, REBECCA COLLINS (PT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:COLLINS
Last Name:KELLY
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 1:302 RAVEN RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4248
Mailing Address - Country:US
Mailing Address - Phone:864-304-2774
Mailing Address - Fax:
Practice Address - Street 1:1014 WADE HAMPTON BLVD STE 6
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609-5061
Practice Address - Country:US
Practice Address - Phone:864-203-3883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2945225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist