Healthcare Provider Details

I. General information

NPI: 1508133752
Provider Name (Legal Business Name): REBECCA CORALYN BACON APC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2011
Last Update Date: 11/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

189 S STATE ST STE 160
CLEARFIELD UT
84015-1061
US

IV. Provider business mailing address

189 S STATE ST STE 160
CLEARFIELD UT
84015-1061
US

V. Phone/Fax

Practice location:
  • Phone: 801-773-2044
  • Fax: 801-773-4826
Mailing address:
  • Phone: 801-773-2044
  • Fax: 801-773-4826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number78488768-6009
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: