Provider Demographics
NPI:1114418456
Name:HARRISON, REBECCA PAULINE (LCPC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:PAULINE
Last Name:HARRISON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:PAULINE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:1020 N POSSUM TRL
Mailing Address - Street 2:
Mailing Address - City:VILLA GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:61956-9503
Mailing Address - Country:US
Mailing Address - Phone:217-372-8715
Mailing Address - Fax:
Practice Address - Street 1:2104 WINDSOR PL STE A
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7773
Practice Address - Country:US
Practice Address - Phone:217-552-1058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-22
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180010584101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty