Healthcare Provider Details

I. General information

NPI: 1639789498
Provider Name (Legal Business Name): REBECCA BASHA HENRY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2020
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8540 BAYCENTER RD
JACKSONVILLE FL
32256-7420
US

IV. Provider business mailing address

8540 BAYCENTER RD
JACKSONVILLE FL
32256-7420
US

V. Phone/Fax

Practice location:
  • Phone: 904-394-5703
  • Fax:
Mailing address:
  • Phone: 904-394-5703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09929381
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number125191
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW16470
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW16470
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: