Provider Demographics
NPI:1891364113
Name:SLACK, REBECCA (PT, DPT)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:SLACK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7112 CHADWOOD LN APT 2C
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-3905
Mailing Address - Country:US
Mailing Address - Phone:740-312-4754
Mailing Address - Fax:
Practice Address - Street 1:1031 MORGANTOWN AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-4355
Practice Address - Country:US
Practice Address - Phone:304-363-0050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH018457225100000X
WV004415225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV004415OtherWEST VIRGINIA BOARD OF PHYSICAL THERAPY
OH018457OtherOHIO BOARD OF PHYSICAL THERAPY