Healthcare Provider Details

I. General information

NPI: 1104600592
Provider Name (Legal Business Name): REBECCA J WELBORN LACA, BSADC,CAPRC II
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BECKY WELBORN LACA, BSADC,CAPRC II

II. Dates (important events)

Enumeration Date: 08/24/2023
Last Update Date: 11/17/2024
Certification Date: 11/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 N STATE ST STE A
GREENFIELD IN
46140-3616
US

IV. Provider business mailing address

304 S JEFFERSON ST
KNIGHTSTOWN IN
46148-1326
US

V. Phone/Fax

Practice location:
  • Phone: 317-406-8191
  • Fax:
Mailing address:
  • Phone: 317-318-4802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberCAPRC2-5198
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number99128120A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: