Provider Demographics
NPI:1356579957
Name:ELLIS, REBECCA MCLAIN (DPT)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:MCLAIN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:230 CLEARFIELD AVE
Mailing Address - Street 2:SUITE 124
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1832
Mailing Address - Country:US
Mailing Address - Phone:757-321-3383
Mailing Address - Fax:757-321-3332
Practice Address - Street 1:1800 CAMELOT DR
Practice Address - Street 2:SUITE 300
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2440
Practice Address - Country:US
Practice Address - Phone:757-321-4284
Practice Address - Fax:757-321-4287
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2011-12-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA2305205989225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA541869072OtherTAX ID
VAC05501OtherMEDICARE GROUP NUMBER