1316257579 NPI number — MS. REBECCA L.K. WILDBEAR LPC

Table of content: (NPI 1346502200)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316257579 NPI number — MS. REBECCA L.K. WILDBEAR LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILDBEAR
Provider First Name:
REBECCA
Provider Middle Name:
L.K.
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316257579
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2201
Provider Second Line Business Mailing Address:
OPEN SKY WILDERNESS THERAPY
Provider Business Mailing Address City Name:
DURANGO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-382-8181
Provider Business Mailing Address Fax Number:
970-382-9494

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
466 SOUTH SKYLANE DRIVE
Provider Second Line Business Practice Location Address:
OPEN SKY WILDERNESS THERAPY
Provider Business Practice Location Address City Name:
DURANGO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-382-8181
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/20/2010

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: 1041C0700X , with the licence number:  5223046-6004 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 5280 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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