Provider Demographics
NPI:1811901978
Name:EBBECKE, DAVID ETHAN (DPT, MBA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ETHAN
Last Name:EBBECKE
Suffix:
Gender:M
Credentials:DPT, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8551 RIXLEW LN
Mailing Address - Street 2:SUITE 340
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-4277
Mailing Address - Country:US
Mailing Address - Phone:703-368-7343
Mailing Address - Fax:703-368-0719
Practice Address - Street 1:8551 RIXLEW LN
Practice Address - Street 2:SUITE 340
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-4277
Practice Address - Country:US
Practice Address - Phone:703-368-7343
Practice Address - Fax:703-368-0719
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305005642225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDQ395-0002OtherCAREFIRST BLUE CROSS AND BLUE SHIELD
MDQ395-0002OtherCAREFIRST BLUE CROSS AND BLUE SHIELD
VA00Y014P03Medicare PIN
VAC10705Medicare PIN