Provider Demographics
NPI:1124643788
Name:ELLIS, REBECCA (LCSW)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:GREGORY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:3833 ANNIE LN
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-2529
Mailing Address - Country:US
Mailing Address - Phone:757-724-7038
Mailing Address - Fax:
Practice Address - Street 1:150 BOUSH ST STE 150
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-1626
Practice Address - Country:US
Practice Address - Phone:757-724-7038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0906010218104100000X
VA09040146591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker