Healthcare Provider Details

I. General information

NPI: 1801249248
Provider Name (Legal Business Name): REBECCA BURROUGHS PTA., CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2016
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 W BROAD ST STE 101
RICHMOND VA
23220-4216
US

IV. Provider business mailing address

5252 LYNGATE CT STE 203
BURKE VA
22015-1672
US

V. Phone/Fax

Practice location:
  • Phone: 804-288-3025
  • Fax: 804-288-3029
Mailing address:
  • Phone: 703-239-2300
  • Fax: 703-239-2301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306604526
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0019013673
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: