Provider Demographics
NPI:1003458308
Name:KING, REBECCA LYNN
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LYNN
Other - Last Name:SEGREST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5212 ALLEGANY DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-5648
Mailing Address - Country:US
Mailing Address - Phone:719-352-2970
Mailing Address - Fax:
Practice Address - Street 1:4003 W STAN SCHLUETER LOOP STE 3
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-6120
Practice Address - Country:US
Practice Address - Phone:254-360-1578
Practice Address - Fax:254-267-1091
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00011928106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician