Provider Demographics
NPI:1033540307
Name:CROFUT, REBECCA ANN PATCH
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN PATCH
Last Name:CROFUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14140 BEACH BLVD
Mailing Address - Street 2:155
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-4453
Mailing Address - Country:US
Mailing Address - Phone:714-896-7556
Mailing Address - Fax:714-896-7564
Practice Address - Street 1:14140 BEACH BLVD
Practice Address - Street 2:155
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-4453
Practice Address - Country:US
Practice Address - Phone:714-896-7556
Practice Address - Fax:714-896-7564
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-11
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA907941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical