Healthcare Provider Details

I. General information

NPI: 1982657433
Provider Name (Legal Business Name): IVYREHAB SEPT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
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

PO BOX 412307
BOSTON MA
02241-2307
US

V. Phone/Fax

Practice location:
  • Phone: 757-467-4604
  • Fax: 757-467-2716
Mailing address:
  • Phone: 914-294-4050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL RUCKER
Title or Position: CEO
Credential:
Phone: 914-294-4050