Healthcare Provider Details

I. General information

NPI: 1033540307
Provider Name (Legal Business Name): REBECCA ANN PATCH CROFUT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2013
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14140 BEACH BLVD 155
WESTMINSTER CA
92683-4453
US

IV. Provider business mailing address

14140 BEACH BLVD 155
WESTMINSTER CA
92683-4453
US

V. Phone/Fax

Practice location:
  • Phone: 714-896-7556
  • Fax: 714-896-7564
Mailing address:
  • Phone: 714-896-7556
  • Fax: 714-896-7564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number90794
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: