Provider Demographics
NPI:1720030257
Name:BLACK, REBECCA A (PT)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:A
Last Name:BLACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:REBECCA
Other - Middle Name:A
Other - Last Name:PRESNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1 MEDICAL PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-7430
Mailing Address - Country:US
Mailing Address - Phone:423-844-4107
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7430
Practice Address - Country:US
Practice Address - Phone:423-844-4107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN830225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3652789Medicaid
TN85539OtherBLUE CROSS
TN3652789Medicaid