Provider Demographics
NPI:1558921023
Name:LOPEZ, REBECCA KATHERINE (PT,DPT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:KATHERINE
Last Name:LOPEZ
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 1:673 BLACKBERRY RUN TRL
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-2128
Mailing Address - Country:US
Mailing Address - Phone:770-656-4776
Mailing Address - Fax:
Practice Address - Street 1:200 WEESE ST
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3758
Practice Address - Country:US
Practice Address - Phone:770-656-4776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPT004319225100000X
GAPT013994225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist