Provider Demographics
NPI:1700900735
Name:ELLIS, REBECCA SUZANNE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:SUZANNE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 STAR AVE
Mailing Address - Street 2:
Mailing Address - City:GLENN HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:75154-2017
Mailing Address - Country:US
Mailing Address - Phone:214-797-1864
Mailing Address - Fax:
Practice Address - Street 1:15600 SAN PEDRO AVE STE 307
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-3739
Practice Address - Country:US
Practice Address - Phone:180-043-7756
Practice Address - Fax:210-545-1657
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209082224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant