1467619239 NPI number — MRS. REBECCA SUE WILLARD LCSW

Table of content: MRS. REBECCA SUE WILLARD LCSW (NPI 1467619239)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467619239 NPI number — MRS. REBECCA SUE WILLARD LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLARD
Provider First Name:
REBECCA
Provider Middle Name:
SUE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILLARD
Provider Other First Name:
BECKY
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1467619239
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3930 8TH ST. SOUTH SUITE 101
Provider Second Line Business Mailing Address:
CHILD & ADOLESCENT PSYCHIATRY CONSULTANTS (BEHREND PSYC
Provider Business Mailing Address City Name:
WISCONSIN RAPIDS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54494
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-423-2030
Provider Business Mailing Address Fax Number:
715-423-2032

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3930 8TH ST S
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
WISCONSIN RAPIDS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54494-6511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-423-2030
Provider Business Practice Location Address Fax Number:
715-423-2032
Provider Enumeration Date:
05/20/2008

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:  6637-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 39771800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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