Healthcare Provider Details

I. General information

NPI: 1447650023
Provider Name (Legal Business Name): MARY-ROSELLEN BANKS DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2014
Last Update Date: 03/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 PROVIDENCE RD SUITE 80
VIRGINIA BEACH VA
23464-4128
US

IV. Provider business mailing address

5301 PROVIDENCE RD SUITE 80
VIRGINIA BEACH VA
23464-4128
US

V. Phone/Fax

Practice location:
  • Phone: 757-467-1900
  • Fax: 757-467-7900
Mailing address:
  • Phone: 757-467-1900
  • Fax: 757-467-7900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305204353
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126000598
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: