Provider Demographics
NPI:1619617446
Name:REVELS, REBECCA BRANCH (PTA)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:BRANCH
Last Name:REVELS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 GILBERT WARD RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:NC
Mailing Address - Zip Code:27892-8088
Mailing Address - Country:US
Mailing Address - Phone:252-341-0612
Mailing Address - Fax:
Practice Address - Street 1:250 LOVERS LN
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-3436
Practice Address - Country:US
Practice Address - Phone:252-975-1636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA5421208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation