Healthcare Provider Details

I. General information

NPI: 1215488564
Provider Name (Legal Business Name): REBECCA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2016
Last Update Date: 10/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 N CASCADE ST
OSCEOLA WI
54020
US

IV. Provider business mailing address

PO BOX 246
OSCEOLA WI
54020-0246
US

V. Phone/Fax

Practice location:
  • Phone: 612-554-8914
  • Fax: 715-417-3103
Mailing address:
  • Phone: 612-554-8914
  • Fax: 715-417-3103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3270 - 226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: