Provider Demographics
NPI:1063000693
Name:ANDERSON, REBEKAH
Entity Type:Individual
Prefix:
First Name:REBEKAH
Middle Name:
Last Name:ANDERSON
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 1:418 NEW GOFF MTN RD STE 201
Mailing Address - Street 2:
Mailing Address - City:CROSS LANES
Mailing Address - State:WV
Mailing Address - Zip Code:25313-1488
Mailing Address - Country:US
Mailing Address - Phone:304-755-9411
Mailing Address - Fax:
Practice Address - Street 1:418 NEW GOFF MTN RD STE 201
Practice Address - Street 2:
Practice Address - City:CROSS LANES
Practice Address - State:WV
Practice Address - Zip Code:25313-1488
Practice Address - Country:US
Practice Address - Phone:304-755-9411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker