Healthcare Provider Details

I. General information

NPI: 1467713040
Provider Name (Legal Business Name): MARY REBEKAH TRUCKS OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2012
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 RIVERSIDE CIR
ROANOKE VA
24016-4950
US

IV. Provider business mailing address

2 RIVERSIDE CIR
ROANOKE VA
24016-4950
US

V. Phone/Fax

Practice location:
  • Phone: 205-223-1605
  • Fax: 540-526-2565
Mailing address:
  • Phone: 205-223-1605
  • Fax: 540-526-2565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number0119005933
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: