1174809040 NPI number — MS. REBECCA ANNE DALLAS BA, CDP

Table of content: MS. REBECCA ANNE DALLAS BA, CDP (NPI 1174809040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174809040 NPI number — MS. REBECCA ANNE DALLAS BA, CDP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DALLAS
Provider First Name:
REBECCA
Provider Middle Name:
ANNE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
BA, CDP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ELLIOTT
Provider Other First Name:
REBECCA
Provider Other Middle Name:
ANNE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1174809040
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2569
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVERETT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98213-0569
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-212-4200
Provider Business Mailing Address Fax Number:
425-212-4200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
811 MADISON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVERETT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98203-4543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-212-4200
Provider Business Practice Location Address Fax Number:
425-212-4201
Provider Enumeration Date:
10/24/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  CP60776411 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)