Provider Demographics
NPI:1114227766
Name:BREIMAN, REBECCA JO (LSAC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:JO
Last Name:BREIMAN
Suffix:
Gender:F
Credentials:LSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-2912
Mailing Address - Country:US
Mailing Address - Phone:801-359-8862
Mailing Address - Fax:801-532-8820
Practice Address - Street 1:514 WILSON AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-2912
Practice Address - Country:US
Practice Address - Phone:801-359-8862
Practice Address - Fax:801-532-8820
Is Sole Proprietor?:No
Enumeration Date:2010-10-29
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7210783-6006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)