Provider Demographics
NPI:1932533056
Name:ELLIS, REBECCA CELESTE (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:CELESTE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 GIN HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:ABBEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29620-3236
Mailing Address - Country:US
Mailing Address - Phone:864-378-4011
Mailing Address - Fax:
Practice Address - Street 1:801 N HAMILTON ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:SC
Practice Address - Zip Code:29697-1061
Practice Address - Country:US
Practice Address - Phone:864-847-7344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-26
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3161251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1104973577Medicaid