Provider Demographics
NPI:1801249248
Name:BURROUGHS, REBECCA (PTA, CMT)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BURROUGHS
Suffix:
Gender:F
Credentials:PTA, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5252 LYNGATE CT
Mailing Address - Street 2:STE 203
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-1672
Mailing Address - Country:US
Mailing Address - Phone:703-239-2300
Mailing Address - Fax:703-239-2301
Practice Address - Street 1:211 W BROAD ST
Practice Address - Street 2:STE 101
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-4216
Practice Address - Country:US
Practice Address - Phone:804-288-3025
Practice Address - Fax:804-288-3029
Is Sole Proprietor?:No
Enumeration Date:2016-07-21
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306604526225200000X
VA0019013673225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist