Provider Demographics
NPI:1902432271
Name:ELLIS, REBECCA SUE
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:SUE
Other - Last Name:SWOGGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2400 SE FEDERAL HWY STE 220
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-4556
Mailing Address - Country:US
Mailing Address - Phone:772-678-6704
Mailing Address - Fax:
Practice Address - Street 1:2400 SE FEDERAL HWY STE 220
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-4556
Practice Address - Country:US
Practice Address - Phone:772-678-6704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-19
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician